LIBRARY OF CONGRESS, 



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UNITED STATES OF AMERICA. 



A HANDBOOK 



DENTAL PATHOLOGY. 



BLODGETT. 



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A HANDBOOK 



DENTAL PATHOLOGY. 



STUDENTS AND PRACTITIONERS. 



ALBERT N. BLODGETT, M.D., 

LATE PROFESSOR OF PATHOLOOY AND THERAPEUTICS IN BOSTON DENTAL COLLEGE. 





PHILADELPHIA: 

P.BLAKISTON, SON & CO., 

1012 Walnut Street. 

1888. 



** 



^ 



** 



Copyright, 1888, 
By P. BLAKISTON. SON & CO. 



WM. F. FELL & CO., 

Electrotypers and Printers, 

1220-24 sansom street, philadelphia. 



PREFACE 



In presenting this volume to the friendly con- 
sideration of the Dental Profession, the best apology 
which the author can offer, is the entire absence of 
any text-book upon the subject of Dental Pathology, 
to which he could refer successive classes of dental 
students for reference or instruction. Under these 
circumstances, and at the request of those whose 
opinions are to be respected, this handbook has been 
prepared. 

The author is conscious that some defects may be 
found in the present treatise. It has been prepared, 
during a large amount of professional and other 
labor. Should a second edition be required by the 
profession, any faults or omissions that may be 
discovered in it will be gladly corrected. The book 
is intended chiefly for students, and therefore is not 
burdened with extensive references to text-books or 
writers, upon whom the author has freely drawn, 
and^to whom he is greatly indebted. 

Boston, September, 1888. 



TABLE OF CONTENTS. 



PAGE 

Pkeface V 



PART I. 

CHAPTER I. 
Anatomy 13 

CHAPTER II. 

The Salivary Glands and Saliva 26 

Pathological Conditions Affecting the Salivary 
Glands, and the Effect of Poisons upon these 
Structures 31 

CHAPTER III. 

Structure of the Teeth 32 

Development of the Tooth 33 

Dentition 35 

Eruption of the Teeth 36 

CHAPTER IV. 
Absorption of the Deciduous Teeth 39 

CHAPTER V. 
Secondary Dentition 43 

CHAPTER VI. 

Development and Eruption of the Secondary Denture 50 

vii 



VI 11 CONTENTS. 

PART II. 

CHAPTER VII. PAGE 

General Pathology of the Teeth 61 

PART III. 

CHAPTER VIII. 

Relation of the Digestive Organs to the Diseases of 
the Mouth and Teeth 67 

CHAPTER IX. 
Bacteria and theib Action in Disorders of the Teeth 78 

CHAPTER X. 

Defective Embryonic Development of the Maxillary 
Structures 84 

CHAPTER XL 
Defective Development— (Continued) 94 

CHAPTER XII. 
Histological Development of the Teeth 100 

PART IV. 

CHAPTER XIII. 

Pathological Conditions Associated with the Second 
Dentition 108 

CHAPTER XIV. 
Anomalies, Formative Defects. Deficiency of Teeth 114 

CHAPTER XV. 
Variations in Size and Location of the Teeth . . .121 



CONTENTS. IX 

CHAPTER XVI. 
Fusion of Adjacent Teeth 128 

CHAPTER XVII. 
Rachitis, 133 

CHAPTER XVIII. 
Inflammatory Affections . 137 

CHAPTER XIX. 
Gangrene of the Pulp 147 

CHAPTER XX. 

Chronic Inflammation of the Tooth and Alveolar 
Process 150 

CHAPTER XXI. 
Caries 159 

CHAPTER XXII. 
Causes of Caries .166 

CHAPTER XXIII. 

Neuroses of the Teeth and Face 179 

PART V. 

CHAPTER XXIV. 
Inflammation 187 

CHAPTER XXV. 

Course and Progress of Symptoms in Acute Inflamma- 
tion 203 



X CONTENTS. 



CHAPTER XXVI. 



l'AI.IC 



Inflammation of Hard Structures and of the Teeth 208 

PART VI. 

CHAPTER XXVII. 
Pathological and Malignant Growths (Tumors) . . . 220 

CHAPTER XXVIII. 
Classification of Pathological Growths ....... 229 

CHAPTER XXIX. 
Hypertrophy 236 

CHAPTER XXX. 
Carcinoma 242 

CHAPTER XXXI. 
Ulceration ix Carcinoma 252 

CHAPTER XXXII. 

Malignant Growths Continued. Sarcoma 258 

Enchondroma • 273 

Index 275 



DENTAL PATHOLOGY. 



PART I. 



CHAPTER I. 

In no branch of Medical Science is it more im- 
portant to possess a clear and satisfactory knowledge 
of the conditions which are present in the state of 
health as well as of disease, than in the care and 
treatment of the mouth and teeth. The results of 
insufficient knowledge, careless examination, or error 
of judgment, in investigation of the oral organs are 
painfully evident to every eye, and the neglect of 
these important structures is sure to be followed by 
disastrous consequences. 

ANATOMY. 

The study of Pathology, whether of the dental 
organs or of other parts of the human organism, is 
so intimately connected with the other branches of 
medical science, that it is not possible to treat of that 
subject entirely independently, but its study must 
necessarily be associated with a knowledge of the 
branches with which it is so intimately connected. 

The study of Dental Pathology can be prosecuted 
2 13 



14 DENTAL PATHOLOGY. 

only after a knowledge of anatomy and physiology ; 
for the science of pathology consists mainly in the 
observation of the various ways in which the parts 
of the body, or the individual organs, have become 
changed from their normal condition to a diseased 
condition. 

In order, therefore, to understand this change, it is 
necessary to possess a knowledge of the state of the 
parts or organs in a state of health. No extended 
description of the anatomical relations of the bones 
or other parts of the face will here be attempted ; the 
student being supposed to have been sufficiently 
instructed in these fundamental branches of dental 
science before essaying to take up the study of 
Pathology. It is the less necessary to enter deeply 
into anatomical details in a work devoted mainly to 
another branch of dental study, because there are 
available to the student valuable books of reference 
upon these subjects, to which he may have recourse. 

It will be remembered that the skeleton of the face 
is composed in great part of those osseous structures 
which, while they form the bony framework to which 
the soft parts are attached, which make up the gen- 
eral character of the face, and produce the features 
of the individual, also give lodgment or attachment 
to a great degree, to the various organs of mastica- 
tion and^ deglutition ; as well as to numerous glands 
and other structures connected with the important 
processes of preparing the food for digestion and 
assimilation. 

The bones which form the maxillary apparatus of 
the upper and lower jaw give almost the entire form 



ANATOMY. 15 

and shape to the lower part of the face ; and deter- 
mine to a great degree the outline of the head as a 
whole. In various pathological conditions, especially 
in some forms of insanity, particularly in those of 
inherited or congenital character, the development 
of the bones of the face, and chiefly those belonging 
to. the maxillary structures, is regarded as of great 
importance in judging of the nature and the gravity 
of the disease. 

The superior maxillary bone, so-called, is to be 
considered as formed of several parts originally, 
which are fused together in later development, to 
form a single bony structure on each side. The 
shape of this bone is irregular, and is variously 
described, but perhaps it may be most correctly 
described as roughly pyramidal. The bone may be 
divided for purposes of study into a body and four 
processes — the nasal, malar, alveolar and palatine. 
The body of the bone is hollow, thus inclosing a 
cavity and forming the antrum of Highmore. The 
outer surface of the bone is irregularly pyramidal, 
the base of the pyramid being placed inward toward 
the cavity of the nose. The nasal process springs 
from the body, and has a direction upward in a ver- 
tical line with the canine tooth. The malar process 
is situated upon the outer surface of the bone, and 
forms the apex of the pyramid. It is characterized 
by great strength, and is of massive form, and articu- 
lates with the malar bone. The palate process forms 
a horizontal plate projecting inward from the body of 
the bone. It forms the roof of the mouth and the 
floor of the nose. The alveolar process is a strong 



16 DENTAL PATHOLOGY. 

and broad ridge of bone which is curved to form the 
complete dental arch, when the bones of the opposite 
sides are united. Upon the outer surface of the 
alveolar process are eminences which correspond to 
the roots of the teeth, and considerable depressions 
exist between them. The prominence over the canine 
tooth is particularly marked. 

There are four surfaces to be described in relation 
to the superior maxillary, viz., the external, the orbit- 
al, sometimes called the superior surface, the internal 
or nasal and the posterior or zygomatic. Upon the 
external surface is seen one of the notable land- 
marks of the facial anatomy, especially in relation 
to the diseases of this region, the canine eminence, 
situated over the root of the canine tooth. Just 
behind this eminence is a deep fossa, the canine 
fossa, which is one of the points of election for the 
puncture of the antrum in diseases of this cavity. 
Immediately beneath the margin of the orbit is seen 
a canal in the bone, the infra-orbital foramen, whence 
issues the infra-orbital nerve. This is one of the prin- 
cipal locations of neuralgic pain in the face, whether 
due to affections of the teeth or to other causes, and 
is the classical seat of tic douloureux. The orbital 
and nasal surfaces form the walls of the antrum in 
these directions. The z} r gomatic surface forms part 
of the zygomatic fossa. At its lower margin is a 
rounded eminence, the maxillary tuberosity, which 
lies behind the wisdom tooth. This portion of the 
bone is the seat of frequent pathological conditions 
due to faulty development of the bone or that of the 
teeth contained within its substance. 



ANATOMY. 17 

The superior maxillary bone articulates with nine 
bones, viz., with two of the cranium — the frontal 
and ethmoid — and seven of the face, viz., the nasal, 
malar, lachrymal, inferior turbinated, palate, vomer, 
and with the superior maxillary of the opposite side. 
Occasionally it is found to articulate with the orbital 
plate of the sphenoid. The bone also gives attach- 
ment to numerous muscles, which are concerned in 
the movements of the lower jaw, and other portions 
of the face ; but no description of these structures 
will be here attempted. 

The lower maxilla consists of a body and two 
rami, which ascend from the body at almost a right 
angle, at a point near its posterior extremity. The 
horizontal portion or body is curved upon itself 
somewhat in the form of a parabola, and presents 
a convex external and a concave internal surface, as 
well as an upper and a lower border. The upper 
border gives insertion to the teeth, and is called the 
alveolar ridge or alveolar process. The external 
surface is marked in the middle line by a slight 
prominence, the symphysis, which is the point of 
union of the two original halves of the jaw. This 
line extends from above downward, and usually is 
moderately prominent at the lower border of the 
bone, forming a tubercle called the mental promi- 
nence. The lower border of the jaw is thinner than 
the upper, and presents at its posterior portion, near 
the angle formed by the ramus, a slight depression, 
in which the facial artery is lodged, as it curves 
around the border of the bone to reach the cheek 
and side of the face. This notch forms a valuable 



18 DENTAL PATHOLOGY. 

landmark in many of the operations of dental sur- 
gery, and should always be borne in mind. A rough 
and somewhat prominent line of bone is seen to pass 
from a point just external to the mental prominence, 
following a direction backward and outward and 
upward, till it reaches the upper border of the bone 
at a point directly behind the situation of the pos- 
terior molar tooth, where it is lost in the base of the 
coronoid process of the ramus. This is the external 
oblique line, and forms the point of attachment of 
several important muscles. Below the root of the 
second bicuspid tooth, on either side, is an orifice in 
the body of the bone, the mental foramen, the ante- 
rior extremity of the inferior dental or mental canal, 
which transmits the mental artery and nerve. 

On the internal surface of the lower jaw, at the 
situation of the symphysis, may be seen four eleva- 
tions, the genial tubercles, which are the seat of 
attachment of muscles concerned in the movements 
of the tongue, as well as in those of deglutition. 
These tubercles afford important points for the meas- 
urement of the jaw in cases of distortion or deformity 
of this bone, and are useful in defining the location 
of pathological changes in the bone or in the struc- 
tures with which it is in relation. Below the genial 
tubercles is observed the commencement of a promi- 
nent line which runs in a direction outward, upward 
and backward, and terminates at a point near the 
centre of the ascending ramus on its inner surface, 
at the place where the inferior dental canal enters 
the body of the bone. The studies carried on by Mr. 
Tomes (see "Manual of Dental Anatomy," page 172 



ANATOMY. 19 

et seq.) would seem to show that the greater portion 
of the increase in the volume of the lower jaw which 
takes place between infancy and adult life is due to 
growth of the body of the bone at a point posterior 
to the location of the deciduous molar teeth, and that 
the additional teeth belonging to the second or adult 
denture are situated in entirely new bone, thus show- 
ing that the increase in length of the body of the jaw 
is principally due to the new formation of bone at a 
point behind the location of the second deciduous 
molar. The five anterior adult teeth thus occupy 
the whole of the space which contained the entire 
primary denture ; the remaining teeth forming the 
additional number belonging to the permanent 
denture are implanted in new-formed bone, produced 
by the lengthening of the body of the lower jaw 
backward, by the recession of the ramus to a situa- 
tion further back than it occupied in relation to the 
primary denture. 

This portion of the jaw is frequently the seat of 
pathological conditions, connected with the develop- 
ment of the bone, or situated in the soft parts which 
there find attachment; as well as of many affections 
due to the defective development or unnatural growth, 
or other disturbed conditions of the teeth contained in 
this part of the jaw. This is particularly true of the . 
wisdom teeth, which are frequently observed to be 
the seat of pathological conditions, either of develop- 
mental or of acquired character. 

The angle which the rami of the jaw forms with 
its body is a variable one, according to the age and 
development of the individual. In infancy it is 



20 DENTAL PATHOLOGY. 

quite obtuse, while in middle life it approaches a 
right angle, to become again more obtuse in mature 
life. As the development of the jaw advances from 
the primitive form which it possesses in the infant, 
and even more markedly in the foetus, the ramus is 
much lengthened, and the two processes, the coronoid 
process and the articular condyle, are relatively in- 
creased in height and changed in shape. 

The condyle in many animals forms a loose joint 
in its articulation with the temporal bone in the 
glenoid fossa, and is capable in these animals of 
extensive motions besides those of the hinge variety, 
by which the jaw is simply raised and lowered. In 
the cavity of the joint is found a thin plate of carti- 
lage, which is attached to the borders of the articular 
cavity, where it is connected with the capsular liga- 
ment of the joint. This cartilaginous layer allows the 
condyle greater freedom of motion than is observed 
in a joint of ordinary character. The condyle of 
the jaw can be moved forward on to the eminentia 
articularis, as the tubercle at the front of the glenoid 
fossa is called, thus permitting a large degree of 
lateral motion in the jaw. This is in man}' classes 
of animals of much service in mastication. It finds 
its greatest development in the ruminants, or those 
animals which chew the cud. This motion is accom- 
plished almost solely by the sliding of the condyle 
of the jaw forward upon the articular eminence, as 
above mentioned. In man the lower jaw possesses 
so great a degree of freedom of movement toward 
the articular eminence, that the condyle sometimes 
slips over the summit of the eminence and becomes 



ANATOMY. 21 

dislocated forward, the condyle lying in the zygo- 
matic fossa. The mouth is then widely opened and 
cannot be closed, the chin is forced backward toward 
the neck, and all the parts are much distorted, and 
the deformity is very great. 

The changes which the lower jaw undergoes after 
birth relate, first, to the alterations effected in the body 
of the bone by the primary and secondary dentitions, 
the loss of teeth in the aged, and the subsequent 
absorption of the alveoli ; second, to the size and situa • 
tion of the dental canal ; and, third, to the angle at 
which the ramus joins the body of the bone. At 
birth the bone consists of two lateral halves, united 
by nbro-cartilaginous tissue, in which one or two 
osseous nuclei are generally found. The body is a 
mere shell of bone containing the sockets of the two 
incisors, the canine and the first molar teeth, imper- 
fectly partitioned from one another. The dental 
canal is of large size, and runs near the lower border 
of the bone, the mental foramen opening beneath 
the socket of the first molar. The angle of the body 
and ramus is obtuse, from the jaw not being as 
yet separated by the eruption of the teeth. After 
birth, the two segments of the bone become joined 
at the symphysis, from below upward in the first 
year; but a trace of separation may be visible in 
the beginning of the second year, near the alveolar 
margin. The body becomes elongated in its whole 
extent, but more especially behind the mental fora- 
men, to provide additional space for the three addi- 
tional teeth developed in this part. The depth of 
the body becomes greater, owing to the increased 



22 DENTAL PATHOLOGY. 

growth of the alveolar part to afford room for the 
roots of the teeth, and by thickening of the subdental 
portion, which enables the jaw to withstand the pow- 
erful action of the masticatory muscles ; but the 
alveolar portion is the deeper of the two, and, conse- 
quently, the chief part of the body lies above the 
oblique line. The dental canal, after the second 
dentition, is situated just above the level of the 
mylo-hyoid ridge, and the mental foramen occupies 
the position usual to it in the adult. The angle 
becomes less obtuse, owing to the separation of the 
jaws by the teeth. In the adult the alveolar and 
basilar portions of the bone are usually of equal 
depth. The mental foramen opens midway between 
the upper and lower borders of the bone, and the 
dental canal runs nearly parallel with the mylo-hyoid 
line. The ramus is almost vertical in direction, and 
joins the body nearly at a right angle. In old age 
the bone becomes greatly reduced in size, for with 
the loss of the teeth the alveolar process is absorbed, 
and the basilar portion of the bone alone remains; 
consequently, tin' chief part of the bone is below the 
oblique line. The dental canal, with the mental 
foramen opening from it, is close to the alveolar 
border. The rami are oblique in direction and the 
angle obtuse. 

The facial bones are intimately related to the 
transformations of the embryonic branchial arches, 
and to the branchial clefts. The median end of the 
first branchial arch projects inward from each side 
toward the large oral aperture. It has two processes' 
the superior maxillary processes, which grow more 



ANATOMY. 23 

laterally toward the side of the mouth, and the in- 
ferior maxillary processes, which surround the lower 
margin of the mouth. From above downward there 
grows an elongation of the basis cranii, the frontal 
process, a broad process with a point at its lower and 
outer angle, the inner nasal process. The frontal and 
superior maxillary processes unite with each other 
in such a way that the former projects between the 
two latter. At the same time there is anchylosed 
with the superior maxillary process the small exter- 
nal nasal process, a prolongation of the lateral part 
of the skull, and lying above the superior maxillary 
process. Between the latter and the outer nasal pro- 
cess is a slit leading to the eye. The mouth is thus 
cut off from the nasal apertures which lie above it. 
But the separation is continued also within the 
mouth ; the superior maxillary process produces the 
upper jaw, the nasal process, and the intermaxillary 
process (Goethe). The latter is present in man, but 
is united to the upper jaw. The intermaxillary bone, 
which in many animals remains as a separate bone 
(os incisivum), carries the incisor teeth. At the tenth 
week the hard palate is closed, and on it rests the 
septum of the nose, descending vertically from the 
frontal process. 

The lower jaw is formed from the inferior maxil- 
lary process. At the circumference of the oral aper- 
ture the lips and alveolar walls are formed. The 
tongue is formed behind the point of union of the 
second and third branchial arches (His), while, 
according to Born, it is formed by an intermediate 
part between the inferior maxillary processes. 



24 



DENTAL PATHOLOGY. 



These transformations in the processes of develop- 
ment may be interrupted by a variety of causes acting 
upon the tissues at any period of their development. 
If the frontal process remain separate from the max- 
illary processes, then the mouth is not separated from 
the nose. This separation may be confined only to 
the soft parts, constituting hare lip, or it may involve 
the hard palate, constituting the varieties of cleft 
palate. Both conditions may occur on one or both 
sides. From the posterior part of the first branchial 
arch are formed the malleus (ossified at the fourth 
month) and Meckel's cartilage, which proceeds from 
the latter behind the tympanic ring, as a cartilagi- 
nous process, extending along the inside of the lower 
jaw almost to its middle. It disappears after the 
sixth month; still, its posterior part forms the internal 
lateral ligament of the maxillary articulation. Near 
where it leaves the malleus is the processus folii. A 
part of its median end ossifies, and unites with the 
lower jaw. The lower jaw is laid down in mem- 
brane from the first branchial arch, while the angle 
and condyle are formed from a cartilaginous process. 
The union of both bones to form the chin, occurs in 
the first year. 

From the superior maxillary process are formed 
the inner lamella of the pterygoid process, the pala- 
tine process of the upper jaw, and the palatine bone, 
at the end of the second month, and, lastly, the 
malar bone. 

The second arch (hyoid) arising from the temporal 
bone and running parallel with the first arch, gives 
rise to the stapes, the eminentia pyramidalis, with 



ANATOMY. 25 

the stapedius muscle, the incus, the styloid process 
of the temporal bone, the stylo-hyoid ligament, the 
smaller cornua of the hyoid bone, and, lastly, the 
glosso-palatine arch (His). 

The third arch forms the greater cornu and body 
of the hyoid bone and the pharyngo-palatine arch 
(His). ^ 

The fourth arch gives rise to the thyroid cartilage 
(His). 



26 DENTAL PATHOLOGY. 



CHAPTER II. 

THE SALIVARY GLANDS AND SALIVA. 

Among the most important structures contained 
within the oral cavity, both as regards the nutrition 
of the body, as well as in relation to the pathological 
processes which are observed in connection with the 
mouth and teeth, are the three bodies which provide 
the digestive secretions of the mouth, the Salivary 
Glands. They are located in the tissues about the 
cavity of the mouth, and are called the Parotid, the 
Submaxillary, and the Sublingual glands, respec- 
tively. 

The Parotid gland is the largest of the salivary 
glands, weighing from half an ounce to one ounce. 
It lies upon the side of the face, immediately below 
and in front of the external ear. Its anterior sur- 
face is grooved to embrace the posterior margin of 
the ramus of the lower jaw, and advances forward to 
meet the ramus, between the two pterygoid muscles. 
Imbedded in its substance is the external carotid 
artery, which ascends behind the ramus of the jaw. 
The posterior auricular artery emerges from it behind, 
the temporal artery above, the transverse facial in 
front, and the internal maxillary winds through it 
inward, behind the neck of the jaw. It is traversed 
from behind forward, by the facial nerve and its 
branches, which emerge at its anterior border ; the 
great auricular nerve pierces the gland adjoining 



THE SALIVARY GLANDS AND SALIVA, 27 

the facial, and the temporal branch of the inferior 
maxillary nerve lies above the upper part of the 
gland. The internal carotid artery and internal 
jugular vein lie close to its deep surface. The out- 
let of the gland is called " Steno's duct." It is about 
two and one-half inches in length. It communi- 
cates with the mouth by a small orifice situated 
opposite the second molar tooth of the upper jaw. 
The direction of the duct corresponds to aline drawn 
across the face about a flnger's-breadth below the 
zygoma, from the lower part of the concha to mid- 
way between the free margin of the lip and the 
alse of the nose. 

The parotid saliva has an alkaline reaction, but 
during fasting, the first few drops may be neutral, or 
even acid, on account of free carbonic acid. Its spe- 
cific gravity is 1003-1004. When allowed to stand 
it becomes turbid, and deposits, in addition to albu- 
minous matter, calcium carbonate, which is present 
in the fresh saliva in the form of bicarbonate. 

Salivary calculi are sometimes formed in the ducts 
of the salivary gland, owing to the deposition of 
lime salts, and they contain the traces of other 
salivary constituents ; in the same way, this salt 
forms the tartar of the teeth, which contains many 
threads of leptothrix, and the remains of low organ- 
isms which live in decomposing saliva and other 
putrefactive substances in carious cavities between 
the teeth. 

- The Submaxillary gland is situated below the 
jaw, in the anterior part of the submaxillary triangle 
of the neck. It is irregular in form, and weighs 



28 DENTAL PATHOLOGY. 

about two drachms. The facial artery lies in a 
groove in its posterior and upper border. The gland 
communicates with the mouth by " Wharton's Duct," 
which is about two inches in length, and opens by a 
narrow orifice on the summit of a small papilla at 
the side of the fraenum linguae. The submaxillary 
saliva is alkaline, and may be strongly so. When 
allowed to stand for some time, fine crystals of cal- 
cium carbonate are deposited, together with an 
amorphous albuminous body. It always contains 
mucin, which may be precipitated with acetic acid ; 
hence it is usually somewhat tenacious. Further, it 
contains ptyalin, but in less amount than in parotid 
saliva. 

The Sublingual gland is the smallest of the sali- 
vary glands. It is situated beneath the mucous mem- 
brane of the floor of the mouth on either side of the 
framum lingua?, in contact with the inner surface of 
the lower jaw, close to the symphysis. It is narrow, 
flattened, in shape something like an almond, and 
weighs about a drachm. Its excretory ducts, of 
which there are several, open separately in the mouth, 
on the elevated crest of the mucous membrane 
caused by the projection of the gland on either side 
of the frsenum lingua?. The sublingual saliva is 
' strongly alkaline in reaction, very sticky and cohe- 
sive, contains much mucin and numerous salivary 
corpuscles. 

The salivary glands are conglomerate glandular 
structures, consisting of numerous lobes, which are 
made up of smaller lobules connected together by 
dense areolar tissue, vessels and ducts. In the sub- 



THE SALIVAKY GLANDS AND SALIVA. 29 

maxillary and sublingual glands, the lobes are more 
loosely united than in the parotid. 

The salivary glands may be divided into different 
classes according to the nature of their secretions. 
1 . The serous or albuminous (true salivary) glands, 
whose secretion contains a certain amount of albu- 
min, as the human parotid. 2. The mucous glands, 
whose secretion, in addition to some albumin, con- 
tains the characteristic constituent, mucin. 3. The 
mixed (muco-salivary glands), some of the acini 
secreting albumin, and others secreting mucin, as the 
human submaxillary gland. 

The most important part played by the saliva in 
the process of digestion, is its diastatic or amylolitic 
action; that is, the transformation of starch into 
dextrin and some form of sugar. Saliva dissolves 
those substances which are soluble in water, while 
its alkaline reaction enables it to dissolve some sub- 
stances which are not soluble in water alone, but re- 
quire the presence of an alkali. Saliva moistens dry 
food, and aids the formation of the bolus, while by 
its mucin it aids the act of swallowing, the mucin 
being given off unchanged in the fauces. The ulti- 
mate fate of the ptyalin is unknown. Saliva also 
aids articulation, while, according to Liebig, it car- 
ries down into the stomach small quantities of oxy- 
gen. It is necessary, to the sense of taste, to dissolve 
sapid substances, and bring them in relation with 
the end-organs of the nerves of taste. 

The secretion of saliva is diminished during in- 
flammation of the salivary glands ; occlusion of the 
ducts by concretions (salivary calculi), also by the 

3 



30 DENTAL PATHOLOGY. 

use of atropine, daturine, and during fever, whereby 
the secretory (not the vasomotor) fibres of the 
chorda appear to be paralyzed. Mercury and jabo- 
randi cause secretion of saliva, the former causing 
stomatitis, which excites the secretion of saliva re- 
flexly. Even diseases of the stomach accompanied 
by vomiting cause secretion of saliva. The reaction 
of saliva is acid in catarrh of the mouth, in fever, 
in consequence of decomposition of the buccal epi- 
thelium, and in diabetes mellitus, in consequence of 
acid fermentation of the saliva, which contains sugar. 
Hence diabetic persons often suffer from carious 
teeth.* 

Unless the mouth of an infant be kept scrupu- 
lously clean, the saliva is apt to become acid. 

The older observers regarded the saliva as a solv- 
ent, and in addition, many bad properties, especially 
in starving animals, were ascribed to it. This arose 
from a knowledge of the infectious qualities of the 
saliva of rabid animals, and the parotid saliva of 
poisonous snakes. Human saliva, without organisms, 
is poisonous to birds. The sal i vary glands have been 
known for a long time. Galen was acquainted with 
Wharton's duct, and iEtius with the submaxillary 
and the sublingual glands. Saliva was obtained for 
purposes of analysis from a horse in 1780, and in 
this } r ear was made the first artificial salivary fistula. 
Spallanzani asserted that food mixed with saliva was 
more easily digested than food mixed with water. 
Hamburger and Siebold investigated the reaction, 

* See chapter ou ' ' Caries. ' ' 



CONDITIONS AFFECTING SALIVAEY GLANDS. 31 

consistence and specific gravity of saliva, and found 
in it mucus, albumen, common salt, calcium and 
sodium phosphates. 

PATHOLOGICAL CONDITIONS AFFECTING THE SALI- 
VAEY GLANDS, AND THE EFFECT OF POISONS 
UPON THESE STRUCTURES. 

Certain affections, such as inflammation of the 
mouth, neuralgia, ulcers of the mucous membrane, 
affections of the gums due to teething, or the pro- 
longed administration of mercury, often produce a 
copious secretion of saliva (ptyalism). 

Certain poisons cause the same effect by direct 
stimulation of the nerves, as Calabar Bean, Digita- 
lin, and especially Pilocarpin. Many poisons, 
especially the narcotics, above all atropine, paralyze 
the secretory nerves, so that there is cessation of the 
secretion, and the mouth becomes dry ; while the 
administration of muscarine, in this condition, causes 
renewed secretion. Pilocarpine acts on the chorda 
tympani, causing a profuse secretion, and, if atropine 
be given, the secretion is again arrested. Conversely, 
if the secretion be arrested by atropine, it may be 
restored by the action of pilocarpine and physostig- 
min. Nicotine in small doses excites the secretory 
nerves, but in large doses paralyzes them. In this 
way we account for some of the results of the use of 
tobacco, as manifested by its action on the salivary 
glands. 



32 



DENTAL PATHOLOGY. 



CHAPTER III. 

STRUCTURE OF THE TEETH. 

A tooth is a papilla of the mucous membrane of 
the gum, which has undergone a characteristic de- 
velopment. In its simplest form, as in the teeth of 
the lamprey, the connective-tissue basis of the papilla 




A FOLLICLE OF MUCOUS CELLS EXTENDING FROM THE DENTAL RIDGE TO THE 

ENAMEL GERMS OF THE MILK AND PERMANENT TEETH; FROM A 

HUMAN EMBRYO OF THREE MONTHS' GROWTH. 

The cells of the mucous layer of epithelium dip down into the substance from 
the dental groove (a) of an incisor of the lower jaw, and resemble, somewhat, 
a tubular gland with lateral offshoots At about the middle of the follicle, 
which is lined throughout with cylindrical cells, it is connected by a trans- 
verse process (6) with the external epithelium of the enamel organ, the 
spongy layer of which is represented (c). The inferior closed portion of 
the follicle is the enamel germ of the permanent incisor tooth. Magnified 80 
diameters. 



STRUCTURE OF THE TEETH. 33 

is covered with many layers of corneous epithelium. 
In human teeth, part of the papilla is transformed 
into a layer of calcined dentine, while the epithelium 
of the papilla produces the enamel; the fang of the 
tooth being covered by a thin accessory layer of bone, 
the crusta petrosa, or cement. The pulp in a fully- 
grown tooth represents the remainder of the dental 
papilla, around which the dentine was deposited. It 
consists of a very vascular, indistinctively fibrillar 
connective tissue, laden with cells. The layer of 
cells, resembling epithelium, which lie in direct con- 
tact with the dentine, are called Odontoblasts, that is, 
those cells which build up the dentine. These cells 
send off long branched processes into the dental 
tubules, while their nucleated bodies lie on the sur- 
face of the pulp and form connections by filaments 
with other cells of the pulp and with neighboring 
odontoblasts. Numerous non-medullated nerve fibres 
(sensory, from the trigeminus), whose mode of ter- 
mination is unknown, occur in the pulp. The peri- 
osteum, or peridental membrane of the root, is at the 
same time the alveolar periosteum, and consists of 
delicate connective tissue, with few elastic fibres and 
many nerves. 

DEVELOPMENT OF THE TOOTH. 

The development of the tooth begins at the end of 
the second month of foetal life. Along the whole 
length of the foetal gum is a thick, projecting ridge, 
composed of many layers of epithelium. A depres- 
sion, the dental groove, also filled with epithelium, 
occurs in the gum, and runs aloug under the ridge. 



34 DENTAL PATHOLOGY. 

The dental groove becomes deeper throughout its 
entire length, and on transverse section it presents 
the appearance of a dilated flask, while at the same 
time it is filled with elongated epithelial cells, which 
form the " enamel organ." A conical papilla (dental 
germ) grows up from the mucous tissue below the 
epithelium, of which the gum at this time consists, 
toward the enamel organ, so that the apex of the 



b 
ENAMEL GERM OF LOWEE BICUSPID PROM EMBRYO OF A CALF. 

The cells lining the walls of the follicle have a cylindrical form (a). The cells of 
the interior are small and flattened The rudiment of the dental ^ac is indi- 
cated hy a shaded outline (6). Between a and b the rudiment of the dentine 
is elevated into papilliforui processes. Magnified 80 diameters. 

papilla comes to have the enamel organ resting on 
it like a double cap. Afterward, owing to the devel- 
opment of the connective tissue, the parts of the 
enamel organ lying between the individual dentine 
germs disappear, and gradually the connective tissue 
forms a tooth sac, inclosing each papilla and its 
enamel organ. The cement is formed from the soft 
connective tissue of the dental alveolus. 




35 







SAGITTAL SECTION OF 

A 

(a) Facial lip of the dental ridge; (6) epithelium; (c) corium, with papilla; in 
the dental ridge, and cavities of transversely divided vessels; (d) enamel 
germ of the permanent incisor containing an aggregation of epithelial 
cells; its connection with the enamel organ of the deciduous tooth d' es not 
appear in the section; («) anterior, (e') pos'erior, osseous lamella of the jaw 
with rounded summits; (/) completed enamel of the dental cap; in the 
section it is separated, somewhat, from the (g) layer of enamel cells; (h) 
retiform connective tissue of the dental sac ; (i) outer epithelium of the 
enamel organ completely investing the papillse of the dental sac; (k) spongy 
layer of the enamel organ; (/) completed dentine of the cap; (m.) layer of 
dentinal cells; (n) dental pulp with wide vessels in its interior. Magnified 
20 diameters. 

DENTITION. 

During development of the first, temporary, decidu- 
ous or milk teeth, another special enamel organ is 
formed near the primary teeth, but it does not un- 
dergo development until the milk teeth are shed. 



36 



DENTAL PATHOLOGY. 



Even the papilla is wanting at first. When the per- 
manent tooth is beginning to develop, it opens into 
the alveolar wall of the milk teeth from below. The 
tissue of this dental sac causes erosion or eating away 
of the fang, and even of the body of the milk teeth, 
without its blood vessels undergoing atrophy. The 
chief agents in the absorption of the deciduous teeth 
are the amoeboid cells of the connective tissue. 

ERUPTION OF THE TEETH. 
The following is the order in which the twenty 
milk teeth cut the gum. From the seventh month 




s'ORMAL PERMANENT DENTURE.— From Wedl. 



to the second year ; lower central incisors, upper cen- 
trals, upper lateral incisors, lower lateral incisors, 
first molars, canines, second molars. The permanent 



ERUPTION OF THE TEETH. 



37 



teeth succeed the milk teeth, the process beginning 
about the seventh year. Ten teeth in each jaw take 
the place of the milk teeth, while six teeth appear 
further back in the jaw. Thus the total number of 
the permanent teeth is thirty-two. As the sacs from 
which the permanent teeth are developed are formed 
before birth, the teeth of the second denture merely 
undergo the same process of development as the tem- 




porary teeth, only at a much later period. The last 
of the permanent molars, " the wisdom tooth," may 
not cut the jaw until the 17th to the 25th year. At 
the sixth year the jaw contains the largest number of 
teeth, as all the temporary teeth are present, and in 
addition the crowns of all the permanent teeth, except 
the wisdom tooth, making forty-eight in all. 



38 DENTAL PATHOLOGY. 

NUTRITION. 

The taking of food may be interfered with by 
spasm of the muscles of mastication (usually accom- 
panied by general spasm of the entire body), stric- 
ture of the oesophagus by cicatrices after swallowing 
caustic fluids, or from syphilis, or caused by the pres- 
ence of a tumor, such as cancer. Inflammation of 
any kind interferes with the taking of food. Impos- 
sibility of swallowing occurs as part of the general 
phenomena in diseases of the medulla oblongata in 
consequence of paralysis of the motor centres, " supe- 
rior olivary processes," for the facial, vagus and 
trigeminus. Stimulation or abnormal excitation of 
these parts causes spasmodic swallowing and the 
feeling of a constriction in the neck, (globus hys- 
tericus). 

The Hippocratic School was acquainted with the 
vessels of the teeth ; Aristotle ascribed an uninter- 
rupted growth to these organs, and he further noticed 
that animals which were provided with horns, and 
had cloven hoofs, had an imperfect set of teeth — that 
the upper incisors were absent. It is curious to note 
thai in some cases in which men have had an ex- 
cessive formation of hairy appendages, the incisor 
teeth have been found to be imperfectly developed. 
The muscles were known at an earty period. Vidius 
described the temporo-maxillary articulation with 
its meniscus in 1567. 



ABSOEPTION OF THE DECIDUOUS TEETH. 39 



CHAPTER IV. 

ABSORPTION OF THE DECIDUOUS TEETH. 

The processes of absorption of any tissue are in 
some ways similar to those observed in certain in- 
flammatory affections. In inflammation of the hard 
tissues, in other parts of the body, there is noticed 
an action upon the bony materials by which they 
are slowly separated from the mass of hard tissue in 
their vicinity, and are at length either reduced to a 
form in which they may be taken up and removed 
by the natural organs of circulation, or they may be 
removed in part by absorption, and the remainder 
may be extruded from the place it occupied in the 
tissues, thus completing the removal of the substance 
from the body. All the hard tissues of the body are 
everywhere permeated by delicate filaments of con- 
nective tissue, which carry on the functions of nutri- 
tion in the part, and are the means of preserving its 
vitality. This is true in the teeth as well as in other 
forms of hard animal tissue, and may be traced into 
the finer canals of the dentine, and has been thought 
to penetrate even the structure of the enamel. 

The processs of absorption of a temporary tooth 
commences at the apex of the root, in cementum 
which has heretofore shown no indications of any 
tendency to disease. The first recognizable step in 
the process of the physiological removal of the pri- 
mary teeth is found in a roughness of the cementum, 



40 DENTAL PATHOLOGY. 

a corrugation of the exterior of the root, with the 
solution, or at least the softening, of the surface of 
the cementum thus affected. This diminution of the 
firmness of the dental textures is then followed by 
the entire removal of the tissue at the root of the 
tooth and a progressive advance of the process of 
absorption toward the mucous membrane, until there 
remains only the margins of the gum to afford 
attachment to the crown of the tooth, the radical 
portion having entirely disappeared from the jaw. 

The exciting cause of the normal absorption of the 
tissues of the milk tooth is the approach of the 
secondary or permanent tooth in the course of its 
development. The second tooth, growing from its 
papilla in an upward direction toward the position 
it is to occupy in the alveolar process, comes into 
immediate proximity with the root of the deciduous 
tooth. The continued increase in the development 
of the secondary tooth is the cause of active phe- 
nomena at the apex of the root of the deciduous 
tooth, which resemble in many respects those of a 
moderate 'inflammation of the root. The result is a 
gradual reduction in the volume of the root, which 
is in an exact relation to the advance of the crown 
of the permanent tooth, so that at the time when the 
deciduous tooth is ready to be extruded from the jaw, 
the crown of the permanent tooth which is to succeed 
it is often visible in the depression left after extrac- 
tion of the remains of the milk tooth. 

The manner in which the absorption of the root 
of the milk tooth is accomplished has been the sub- 
ject of careful study, and many theories have been 



ABSORPTION OF THE DECIDUOUS TEETH. 41 

advanced to explain this singular phenomenon. The 
most celebrated investigators in the domain of dental 
science have given the subject much attention. 
Czermak, Bodeker, Tomes, and, more recently, Abbott 
(see Independent Practitioner, July, 1884) have made 
valuable contributions to the solution of the question, 
which, however, cannot yet be said to be absolutely 
settled. All observers unite in describing the grad- 
ual excavation or corrugation of the hard textures 
of the root of the tooth, very similar to the appear- 
ances noticed in the absorption of portions of ivory, 
surgical catgut, silk, etc., when brought into relation 
with the textures of the living and healthy organism. 
The substance of these materials is invaded by nu- 
merous cavities, in which a softened and jelly-like 
content is found, and which penetrates further and 
further into the textures of the tissue. The advance 
of the process of softening is followed by continuous 
absorption of the disintegrated textures of the tooth, 
and in this way is brought about the removal of the 
entire radical portion of the dental structures. There 
is no attending suppuration in the process of absorp- 
tion, and the entire course of the process is devoid of 
pain. There is often a certain amount of redness 
and swelling of the soft structures about the neck of 
the deciduous tooth during the process of absorption, 
but this may well be due, in part at least, to the 
irritation of the tissues about the part, caused by 
pressure upon the shortened and loosened deciduous 
tooth, and also to the natural tendency to vascularity 
accompanying any process of growth or development. 
The process of natural absorption of dentinal tissues 



42 DENTAL PATHOLOGY. 

bears no relation to caries of these textures. This 
event is one of natural removal of normal structures. 
Caries is the pathological degeneration of the same 
structures by means of disease, and is accompanied, 
if not caused, by chemical action, and is universally 
the seat of disorganization of the tissues of the tooth ; 
it is also accompanied by the presence of bacterial 
organisms, and usually also by the putrefaction of 
the products of the disorganization of the tooth sub- 
stance. Caries takes its rise at all times from with- 
out. Absorption progresses from the apex of the 
root. Absorption is accompanied by a new formation 
of medullary or myxomatous tissue, which invades 
the tooth structure and changes it into a material 
which can be taken up by the natural channels of 
the part. In caries the softening is caused by the 
chemical decomposition of the calcined textures of 
the tooth-structure, is accompanied by putrefaction 
and the presence of microorganisms. In physio- 
logical absorption there is simple removal of the 
softened tissues without the occurrence of putrefac- 
tion or the presence of microorganisms. Further 
researches in the domain of absorption of the hard 
tissues, and especially those of the deciduous teeth, 
are greatly needed, and it is to be hoped that from 
such studies the obscure points in relation to the 
physiological removal of the hard tissues may be 
elucidated. 



SECONDARY DENTITION. 43 



CHAPTER V. 

SECONDAEY DENTITION. 

The phenomena associated with the disappear- 
ance of the first teeth, and their replacement by the 
teeth of the permanent denture, form one of the 
most interesting and important studies connected 
with the oral organs. The pathological conditions 
arising from any derangement of this process, or 
connected with any disease of the parts involved, 
form a separate and distinct group, of unique char- 
acter. As is well known, the primary denture is 
developed in the early months of infantile life, and 
is composed of teeth of small size, contained in a 
dental arch of comparatively limited capacity. The 
teeth thus formed are sufficient to fill the arch of the 
infantile mouth, and form a complete dental formula 
for that period of the life of the individual. As the 
body of the child is developed, and every part and 
organ is advancing to a greater size, with the adult 
development of the organism, the dental arch is en- 
larged, and the entire outline of the lower part of 
the face is changed in all its proportions. The teeth 
which were sufficient for the earliest years of life are 
no longer adequate for the purposes of the adult 
frame, and the jaw has become so much larger that 
the teeth are in comparison dwarfed and weazened, 
and in no sense suffice for the requirements of 
the organism. The extent of the change which has 



44 DENTAL, PATHOLOGY. 

occurred is not easily appreciated by the observer, 
unless occasion should offer for a comparison of the 
relative proportions of the jaw and the contained 
teeth. In some cases in which the normal develop- 
ment of the second denture has been interrupted, 
the teeth of the first denture are retained long after 
the time when they should have been physiologically 
replaced by those of the permanent set. Under such 
conditions we may sometimes find the infantile teeth 
of the primary denture still retained in the alveolar 
process of the mature jaw, they, of course, retaining 
their original size and shape, while the teeth of the 
second denture on either side of them are large and 
massive. The retained primary teeth are often pre- 
served until advanced life, they seeming to possess a 
similar degree of vitality to that of the permanent 
teeth by which they are surrounded. 

One of the chief results of their detention in the 
adult jaw is the restricted development of the dental 
arch, which should normally be symmetrically en- 
larged in all directions to accommodate the increased 
number of teeth belonging to the secondary denture, 
each tooth of which is also of larger size than those 
of the primary denture. If, therefore, the teeth of 
the first denture are retained in the dental arch of 
the subject beyond the period when they should 
normally give place to the members of the second 
denture, two principal pathological conditions are 
induced in the jaw, each of which contributes to the 
permanent deformity of the facial region and to the 
impairment of the physiological functions of the 
oral organs. 



SECONDARY DENTITION. 45 

The retention of the small infantile teeth in the 
massive jaw of adult development is associated with 
the restricted growth of the alveolar process within 
the area of the infantile teeth. The alveolar process 
is developed in proportion to the teeth which it is to 
contain, and it is often observed that if the teeth of 
the first denture are indefinitely retained in the jaw, 
the alveolus is restricted in its development to the 
size required for the accommodation of the teeth 
actually contained in the jaw. The normal and 
symmetrical enlargement of the jaw to correspond 
with the increasing size of the adult structures 
generally, does not occur in the mouth when the 
members of the primary denture are unduly or 
permanently retained in the alveolar process. 
The consequence of this is that the alveolar process 
in the region of the retained teeth is usually shorter 
than normal, being restrained in its development to 
the size requisite for the teeth actually contained in 
the jaw, and not acquiring the size which would 
have been reached had normal development occurred. 

The effect of the retention of the deciduous teeth 
is to diminish the size of the arch of the alveolus, so 
that it is only sufficient for the teeth actually con- 
tained in the jaw, and does not at all conform to the 
development of the adjacent structures of the head 
and face. The result of this is seen in a pointed form 
of the jaw, a narrowing of the lateral measurements 
of the alveolar arch, and often a sinking backward 
of the entire contour of the lower portion of the face. 
The chin becomes sharp and pointed, the lower teeth 
are sometimes placed far behind the upper, the facial 



46 DENTAL PATHOLOGY. 

outline retreats in a marked manner from the nasal 
process of the superior maxillarj' - , so that at times a 
line drawn from the base of the nasal cartilage to 
the prominence of the cricoid cartilage of the larynx 
will not touch the chin or the lower lip. The de- 
formity thus produced is very marked, and is usually 
irremediable. 

The second effect produced by the retention of the 
deciduous teeth is the interference with mastication 
and speech. For the proper execution ©f each of 
these important functions it is necessary that there 
should be accurate closure of the dental organs, 
and correcl apposition of the upper with the lower 
members of the denture. The teeth of the primary 
denture are so diminutive that they cannot make a 
useful contact with those of the normal secondary 
denture, and therefore the act of mastication is 
imperfectly performed; if indeed these organs can 
properly be called organs of mastication. The speech 
is affected from the inability to close the anterior 
opening of the mouth by the teeth, and thus is 
produced a lisping articulation, similar in some 
respects to that observed in the pronunciation of 
certain consonant sounds in persons with a cleft in 
the hard or soft palate. 

The phenomena attending the disappearance of 
the deciduous teeth, and their replacement by those 
of the permanent set, are among the most curious to 
be observed in any of the physiological processes of 
the human body. The development of the decidu- 
ous teeth from the primary dental follicle and the 
primitive enamel germ has already been briefly 



SECONDARY DENTITION. 47 

alluded to in another place. It was also stated that 
from the dental germ of the deciduous tooth a pro- 
longation of the substance of the dental follicle was 
given off, which remained dormant in the alveolar 
process during a great part of the time while the 
deciduous teeth were in existence, but which at 
length began to develop, and produced the teeth of 
the permanent denture ; being developed gradually, 
and appearing at intervals in the jaw, the last teeth 
being erupted at about the eighteenth to the twenty- 
fifth year. The manner in which the disappear- 
ance of the primary denture is brought about has 
long been the object of study by histologists, but 
the process is one which is clothed with more than 
usual obscurity, and its investigation has been 
attended with great difficulty. From the best obser- 
vations, however, it is now possible to outline the 
physiological course of events somewhat as follows, 
though the investigations of many competent observ- 
ers are not wholly in accord upon the subject. It 
may also be added that the results thus far obtained 
and the opinions thus far formed are founded upon 
the basis of experimental pathology fully as much as 
upon the observation of the physiological occur- 
rences accompanying the loss of the temporary teeth. 

It is well known that if certain substances are in- 
troduced into the tissues of the human body and are 
allowed to remain there, the system not only retains 
them, but is not seriously disturbed by their pres- 
ence. 

Thus, in certain cases of fracture of the long bones, 
in which for some reason the ends of the broken bone 



48 DENTAL PATHOLOGY. 

have failed to unite, it has been customary to drive 
ivory pegs into the ends of the bones, in order to 
excite the parts to renewed activity, and thus 
encourage the union of the fracture. In many in- 
stances it has been observed that those portions of 
the ivory which were included in the bony tissue 
have been entirely removed by the action of the 
tissues of the part, and there has remained only 
that portion of the ivory which was outside the bone. 
The disappearance of the ivory is due to the absorp- 
tion of the substance, to the dissolution of the ivory 
by the natural processes of the body, and its removal 
in the form of soluble or oxydizable compounds. 
Again, in cases of fracture in which the process 
of healing goes on in the ordinary manner, there is 
first formed a large mass of hard material about the 
ends of the fractured bone, which incloses them in 
much the same manner as a plumber incloses the 
ends of a pipe, which are to be united, in a thick mass 
of solder. The tissue which is thrown out about the 
em Is of the broken bone is called " callus," and serves 
to hold the ends of the bone in apposition one with 
the other, and to prevent their displacement in any 
direction. When the ends of the bone have thus 
been cemented together by this large mass of callus 
on the outside, the process of union of the broken 
ends commences in the tissues of the bone, and is 
carried on until the point of fracture has been fully 
healed. When this has been accomplished, and the 
bone is strong, then the callus, which had been 
thrown out in order to support the parts during the 
process of healing, is removed by gradual absorption, 



SECONDARY DENTITION. 49 

and after a time there is no trace of it to be discov- 
ered. If, by any chance, the bone has united in a 
faulty manner, as is at times the case, so that a sharp 
angle is formed at the point of union, we find that 
after a time the sharp corner is removed and the 
surface is smoothly rounded by the absorption of the 
superfluous material, and the contour of the bone is 
made smooth and even. So, too, after amputation 
of a long bone in one of the limbs, it is uniformly 
observed that the end of the bone is gradually 
rounded and smoothed by the process of absorption 
of the sawed edges, and the growth of a covering of 
bone over the open end of the medullary cavity. 
Tnus we see that nature possesses the power to pro- 
duce considerable amounts of hard material in cases 
of repair of the tissues of the bones, and that such 
deposits of hard tissue may afterward be easily, and 
completely removed from the place where they were 
deposited, and the part restored to its former condi- 
tion. 



50 DENTAL PATHOLOGY. 



CHAPTER VI. 

DEVELOPMENT AND EEUPTION OF THE SECONDAEY 
DENTUEE. 

Iii the processes attending the shedding of the 
primary teeth, and their replacement by the mem- 
bers of the permanent denture, we may notice the 
same peculiarity which has been observed in regard 
to the long bones in other parts of the body. 

At a period subsequent to the development of the 
deciduous teeth, the germs of the secondary dental 
follicles, which have been deposited by the dental fol- 
licles of the first dentition in the alveolus of the up- 
per and the lower jaw, become active. Soon there is 
seen the appearance of tooth structure, and at a later 
period there are unmistakable evidences of the for- 
mation of complete dental organs of a larger size and 
more massive structure than those already in the 
jaw. As the new teeth are formed, they advance in 
the jaw toward the surface of the alveolar process. 
In their progress they soon come to be placed directly 
under the bodies and roots of the deciduous teeth 
which already occupy the jaw. As the secondary 
teeth advance in direction, and encroach more, and 
more upon the structure of deciduous teeth, the roots 
of these teeth are seen to diminish in length, and to 
undergo a loss of substance from the absorption of 
their extremities and removal of their tissues, so that 
at last, at the time when the milk teeth are shed, or 



DEVELOPMENT OF SECONDARY DENTURE. 



51 



are become so loose as to require extraction at the 
hands of the dentist, there remains nothing but the 
crown, and a little border of the submucous surface 
of the deciduous tooth, which is held in position only 




SET OF MILK TEETH, WITH THE CORRESPONDING PERMANENT TEETH STILL 
IMBEDDED WITHIN THE JAW. 

The first permanent molars (a) have already emerged from the jaw, both above 
and below, so that the second dentition has commenced. Profile view from 
the right side. The somewhat inclined crowns of both permanent incisors 
are visible behind the extremities of the roots of the milk incisors. The 
crown of the upper canine tooth (6) presents a marked inclination, and is 
situated high up in its alveolus; the lower permanent canine (c) likewise 
occupies a deep position. The crowns of the permanent bicuspids are 
grasped by the diverging roots of the milk molars. The mental foramen (d) 
is seen between the first and second milk teeth. The crowns of the second 
permanent molars, inclosed within their alveoli, are imbedded in the maxil- 
lary tuberosity and coronoid process. Natural size. 



by the attachments of the mucous membrane. On 
removing a tooth so loosened, the crown of the per- 
manent tooth may often be seen already appearing 
in the place formerly occupied by the deciduous 



52 DENTAL PATHOLOGY. 

tooth, the advancement of which has caused the 
physiological absorption and removal of the root of 
the deciduous tooth, and in this way brought about 
the physiological loss of these first dental organs, in 
order to provide a location for the permanent den- 
ture, which is in size and structure adapted to the 
requirements of the adult body during the lifetime 
of the individual. 

In the occurrence of the second dentition we have 
a totally different dental formula from that observed 
in the primary dentition. The second or permanent 
denture contains representatives of all the teeth of 
the primary denture, and in addition to these we 
find three teeth upon each side of the median line, 
which were not' represented at all in the primary 
denture. The jaw is also much larger and the 
alveolar ridge relatively elongated in the adult. If 
now we take the jaw of a child, in which the com- 
plete primary denture is present, and apply it to the 
jaw of an adult, containing all the teeth of the per- 
manent denture, we shall find that the entire infan- 
tile jaw corresponds to that part only of the adult 
jaw which is comprised in that portion of the adult 
denture consisting of the incisors, the canines and 
the two bicuspids, or premolars. The remaining 
portion of the adult denture has no development in 
the infantile jaw, and is located beyond the area of 
the alveolus in the mouth of a young child. Care- 
ful investigation upon the position of the teeth in 
the deciduous and in the permanent denture, made 
by Tomes and others, seems to demonstrate that the 
additional teeth of the adult denture are placed in 



DEVELOPMENT OF SECONDARY DENTURE. 



53 



that portion of the alveolar process which has been 
developed behind the location of the members of 
the deciduous denture. It- is thought that the coro- 
noid process of the lower jaw moves gradually back- 
ward, and that the alveolar process is thereby 
elongated so as to afford space for the additional 
teeth of the adult denture, and that the coronoid 
process has thereby occupied every position between 
the location of the first molar tooth and that which 




(a), lowest point in the junction of the anterior portions of the two segments of 
the upper jaw, from a fcetus in the seventh month ; (6), central point of the 
space between the edges of the two central incisors of a set of milk teeth ; 
(c), the same of a permanent set. 



it finally assumes when the development of the 
denture is at length complete. Thus it would seem 
that the enlargement of the jaw, and its augmented 
alveolar space is provided by the gradual retreat of 
the coronoid process to a position further and 
further backward, and in the space so provided, the 
additional teeth of the adult denture, which are all 
molar teeth, find place in the jaw. 



:.l 



DENTAL PATHOL* >GY. 



The origin of the molar teeth, by which is meant 
those teeth which are additional to the Dumber con- 
tained in the primary denture, has long been an 
unsettled question, and it is do! yet certainly known 
how they arc produced. The most commonly 
accepted theory at present is something like the fol- 
lowing: The deciduous teeth at the time of their 




(a) the highest point in tl ction of the nntorior surfaces of the two 

evei ths. The resl <>f the 

li tiers indicate c irresponding points with those in the la.st figure. Natural 



development in the infant, send off germs from the 
denial follicle, which serve as the origin of the den- 
tal follicle for the permanent teeth. Each of the 
deciduous teeth thus provides for the development 
of its succeeding permanent tooth. The posterior 
infantile molar thus -ends off the germ for the 
second bicuspid, of the permanent denture. Jt is also 



DEVELOPMENT OF SECONDARY DENTURE. 55 

thought to give off a germ for the development of 
the first permanent molar, which appears imme- 
diately behind it at about the seventh or eighth 
year. The first molar in the same way sends off a 
germ for the development of the second molar, and 
this in its turn gives off a germ for the development 
of the third molar or wisdom tooth, which usually 
appears at about the twentieth year. 

The correctness of the conclusions here advanced 
in relation to the origin of the additional teeth of 
the adult denture is strikingly confirmed by the 
study of certain pathological conditions associated 
with the second denture. In certain cases the full 
denture fails to appear in the mouth, one or more 
teeth failing to erupt, and the jaw is not infrequently 
the seat of more or less distortion and deformity. 
Further, there is often a sinus leading from the sur- 
face of the mucous membrane of the gum into the 
tissues of the part. When this condition exists, there 
is usually also a continuous and offensive purulent 
discharge from the opening of the sinus, which causes 
great distress to the patient and seriously endangers 
the health. A probe inserted into the sinus will often 
touch necrosed or denuded bone. In many instances 
the adjacent molar tooth is also the seat of pain, or 
is loosened or otherwise impaired in its integrity. 
In more than one instance in which such cases have 
been observed by the writer, and operation has been 
advised, it has been found that the distortion was 
occasioned by the presence in the jaw of a distorted 
and malformed tooth, which was intimately fused 
with the body of the second molar below the level of 



56 DENTAL PATHOLOGY. 

the mucous membrane. It is probable that in the 
development of the germ for the third molar, the 
normal process was in some way disturbed, and the 
germs of the second and third molars were in con- 
tiguity. The development of the second molar was 
accomplished without interruption, but when the 
third molar was developed at a later period, the 
growing germ was brought into so close relationship 
with the structure of the second molar that fusion of 




AN OBSTACLF. TO THE I>F.S< 'F.NT OF Till: KIGHT UPPER WISDOM TOOTH, IN A 
FACIA! VIEW OF THE POSTERIOR SEGMENT OF THE UPPER JAW. — From \Vedl. 

The first molar was detached some time previously; the second is inclined ante- 
riorly, and the extremity of the posterior facial root (a) lias a corresponding 
deviation posieriorly, and presses against the descending masticating surface 
of the wisdom tooth", the facial surf ice of which (6) has been exposed by the 
removal of the alveolar wall. Two-thirds natural size. 



the two occurred, with the subsequent distortion of 
the growing tooth and its retention as a misshapen 
mass of confused structure, firmly attached to some 
part of the adjacent tooth. As the deformed tooth 
grew larger, it caused absorption of the thin layer of 
alveolar process above it, and the mucous membrane 
which then covered it was perforated, thus allowing 
free communication between the cavity of the mouth 
and the retained tooth. The intrusion of particles 



DEVELOPMENT OF SECONDARY DENTURE. 57 

of food or other substances into the cavity containing 
the tooth would naturally be followed by suppura- 
tion, and there would be a constant discharge from 
the orifice of the cavity. In the cases seen by me 
there was subsequent inflammation of the alveolar 
process, with implication of the neighboring tooth, 
which became painful and tender. On endeavoring 
to examine the condition of the alveolus, a hard and 
smooth body was uniformly felt in the jaw, inclosed 
in a bony cavity, which presented rough and jagged 
walls. It was in each case necessary to enlarge the 
opening which led down to the offending body, by 
removing a portion of the alveolar wall, when it 
could be plainly observed that the cause of the 
trouble was a retained tooth, usually much distorted, 
and bearing no resemblance to the normal shape or 
structure of a molar tooth. When the retained tooth 
was fused to the root of the second molar, there was 
generally an extension of the inflammatory process 
to this tooth, and the patient usually presented him- 
self for the purpose of having the second molar 
removed. In no case of this kind was there an 
erupted third molar present in the jaw, and in no 
case was there any history of the loss of that tooth 
by extraction or disease. On endeavoring to extract 
the affected tooth, when this was clone, it was found 
impossible to remove it, and on subsequently open- 
ing the alveolus behind the body of the tooth, as 
was generally advised, a glistening white body was 
exposed, which could be moved by the exercise of 
force, and was observed to cause a movement of the 
adjacent second molar. On again attempting the 



58 DENTAL PATHOLOGY. 

extraction of the second molar, it was easily accom- 
plished, with the removal of the attached third molar. 
Three specimens in my possession illustrate in a very 
complete manner the deformity here described, and 
show the way in which the misplacement of the 
germs of the second dentition may produce patho- 
logical conditions in the denture, which have for 
their result the loss of important organs. The facts 
observed in this condition also indicate that the 




1 NIOB OF THE ROOTS OP TIIH 1 I'lli: si:i'u\i> MOLAR "N T THE LEFT SIDE, WITH 
THOSE OB mi: WISDOM TOOTH, AS SEES FBOM THE FACIAL Sli)li. 

The posterior facial root of the second molar, which has !>eeu filed away to show 
the root canal, impinges upon the anterior facial root of the wisdom tooth, 
and is united to it by means of cement ; in the same manner, the lingual 
root of the second molar is united with the anterior facial root of the wis- 
dom tooth by means of a quite thick layer of cement. These teeth were 
extracted on account of chronic inflammation of the root-membrane and 
suppuration of the gum. Natural size. (For the use of this specimen the 
author is indebted to Dr. Jurie Gustav.) 



germ for the third molar tooth is derived from the 
dental follicle of the second tooth, and is liable to 
fusion with this tooth in case any accidental disturb- 
ance of its normal location in the jaw, or in its 
development afterward, should arise. 

In some cases the retained tooth may pierce the 
inner or the outer table of the jaw, and may then 
be followed by an abscess in the soft parts, which 



DEVELOPMENT OF SECONDARY DENTURE. 59 

may open by an independent orifice upon the sur- 
face of the face. When the retained tooth is con- 
tained within the upper jaw, it may perforate the 
floor of the nose, and thus give rise to the signs of 
disease of this cavity, either in the general fossa of 
the inferior meatus, or in the antrum. This condi- 
tion may become serious from the reason that a 
canal is opened by which fluids or other substances 
may pass from the cavity of the mouth into that of 
the nose, thus keeping up the diseased condition in- 
definitely. Extraction in these cases is then followed 
by a naso-buccal fistula, which may cause both the 
patient and the dentist much annoyance. At times, 
when the retained tooth is not attached to the other 
teeth, it may ascend bodily, and be extruded into the 
nasal fossa, or into the antrum. This accident is 
often followed by the symptoms of suppurative dis- 
ease of this cavity, and when the wall of the antrum 
is punctured for its relief, the tooth may be found 
lying in a mass of granulations, which have sprung 
up around it. The removal of the offending body 
may not be followed by relief in all cases, owing to 
the diseased condition of the surrounding structures, 
which has been occasioned by the prolonged irrita- 
tion caused by the gradual extension of the tooth 
through the nasal mucous membrane, and its re- 
tention in abnormal relations, and the irritation of 
the delicate mucous lining of the cavity in which 
it is contained. 

Among the rarer pathological phenomena asso- 
ciated with the retention of teeth, or their malposi- 
tion in the jaw, is the paralysis of certain domains of 



60 DENTAL PATHOLOGY. 

the facial area, either in sensation, or motion, or both. 
This may be occasioned in several ways, but is prob- 
ably most commonly caused by the extension of the 
inflammation attending the ulceration of the jaw 
around retained teeth, to the soft parts about the 
alveolar process, which may occasionally involve the 
region of the parotid gland, or the tissues imme- 
diately adjacent, thus causing pressure upon the 
trunk of the facial nerve in that part of its course 
which lies within the substance of the parotid, or 
near this gland. It is important to carefully investi- 
gate all cases of facial paralysis, in order to ascertain 
if any affection of the teeth or mouth be the active 
cause of the disability. This is the more necessary, 
as the prolonged existence of paralysis is followed by 
the atrophy of the muscles supplied by the paralyzed 
nerve, and then the deformity and distortion become 
permanent. 

Thus we find that many conditions of grave char- 
acter, and serious import to the well-being of the 
individual, may be associated with the disturbance 
of the processes attending the second dentition, and 
that often a permanent deformity, either of the 
denture or of the features, may result from acci- 
dental deviations in the normal development of the 
permanent teeth. To prevent distortion, no less than 
to heal diseases, is the province of the medical ad- 
viser, in regard to the teeth, as well as in relation to 
the other structures of the human body. The den- 
tist who neglects either of these functions, fails to 
perform his duty to his patients. 



PART II. 



CHAPTER VII. 

GENERAL PATHOLOGY OF THE TEETH. 

In attempting the special study of dental Path- 
ology, attention is properly first directed to those dis- 
eases or abnormal conditions of the general system, 
which, by their existence or their effects, produce 
disease of the teeth themselves, or awaken destruc- 
tive changes in the neighboring organs. The con- 
sideration of the relations existing between the 
various structures contained within the oral cavity, 
the manner of their arrangement one toward 
another, the nature of their coincident affections, 
and the extent to which the organs and parts in the 
vicinity may become involved in the disturbances 
of the teeth and their surroundings ; and the way in 
which even remote organs may be affected by dis- 
eases of the teeth, must attract the earnest attention 
of the dental surgeon. 

Cases are not infrequently observed in which some 
disorder of nutrition which may be due to one of 
many general causes, and which affects the system 
at large, is also seen to act locally upon the oral 
structures; and thus by the interference with the 
functions of the system at large, destructive changes 
G Gl 



62 DENTAL, PATHOLOGY. 

may be induced in the teeth, or in other organs in 
the immediate vicinity. ■ 

The disease of some important viscus remote from 
the mouth, may be followed by the appearance of 
pathological changes in the dental organs, from the 
lowering of the tone of the system, and the diminu- 
tion of the general strength ; or from other causes. 

The dentist is frequently consulted upon patho- 
logical conditions in the oral organs which are 
plainly due to a general disease, and in which the 
treatment must be directed to the care of the sys- 
temic disorder, fully as much as to that of the teeth 
themselves. 

The occurrence of tetanus or lockjaw after surgical 
injuries comes under this head, as well as many 
other accidental conditions which are associated with 
the existence of remote diseases, acting through the 
nervous system, or producing disturbance of the oral 
structures by interference with the circulation, or in 
other ways. 

Another marked difference in the character of 
many of the diseases affecting the teeth is due to the 
circumstances of age of the patient, the existence of 
hereditary tendencies, the presence of deformities, or 
the congenital absence of more or less important 
parts. The sex of the patient may also have an 
important bearing upon the origin and course of 
many diseased conditions of the oral structures, as 
well as upon the other organs and functions of the 
body. 

The dentist who should fail to recognize the con- 
stitutional origin of the dental disease in such cases 



GENERAL PATHOLOGY OF THE TEETH. 63 

as are here alluded to, would overlook the most im- 
portant feature in determining the treatment of the 
case. 

Certain defects in development, by which some of 
the parts may become displaced or distorted, are 
often followed by complicated and distressing dis- 
turbances of nutrition, and consequent actual disease 
of the structures involved. 

The direct violence of mechanical injuries by 
which the continuity of the tissues may be disturbed, 
or the circulation within the part be modified, or the 
nervous distribution interrupted or gravely affected, 
may be followed by serious changes in the structure, 
or the functional integrity of the jaws and teeth. 

Chemical action of various kinds is not infre- 
quently the cause of disorganization, more or less 
extensive, of the structure of the dental organs. This 
category includes those substances which act locally, 
by actual contact with the tissues of the tooth, as 
well as those which induce a gradual change in the 
integrity of the dental tissues, as the consequence 
of other and extensive action in and through the 
entire system. 

The characteristic appearances which are observed 
in the teeth of the aged, the changes in their anatomi- 
cal structure, and the senile decadence which they 
undergo, form the closing paragraph in the general 
survey of the field of dental Pathology. The devia- 
tions in shape, and the changes in structure of the 
jaws at different periods of life, from the first appear- 
ance of the tooth germs to the slender and atrophied 
lower maxilla of toothless old age, are not here 



64 DENTAL PATHOLOGY. 

included, but will be considered at the proper place, 
as a distinct subject. 

The study of the diseases of the teeth themselves 
should consist in an endeavor to ascertain in what 
way the structures of the tooth have been affected, 
how its tissues have been changed, its functions 
perverted, the surrounding tissues affected, or even 
destroyed. We should consider the various forms 
of disease of the bones in which the teeth are fixed, 
the occurrence of exostosis and hyperostosis and 
other malformations of the dense tissues, the inflam- 
mations of the soft parts, and the retrogressive 
changes, such as senile degeneration and dental 
atrophy. The affections of the investing mucous 
membrane of the tooth, as well as those of the pulp- 
cavity are classified by themselves. Another class 
of pathological processes is due to the effects of 
injudicious diet, or insufficient nutrition; and still 
another group of affections is the result of the direct 
action of chemical or other irritant or corrosive sub- 
stances. 

The investigation of the cancerous and other ma- 
lignant growths would form a separate study, inas- 
much as the character of the growth is usually in no 
way different when located in the mouth, from what 
is observed in other parts of the body. The litera- 
ture upon the relation of systemic diseases to the 
lesions of the dental organs is extremely scanty. The 
most popular and best known text-books hardly 
allude to the subject. When we consider the import- 
ance of this subject, we must feel some degree of sur- 
prise that attention has not been more forcibly 



GENERAL PATHOLOGY OF THE TEETH, G5 

directed to the great influence of the general condi- 
tion of the health upon the state of the growing den- 
ture, either in the way of modifying its development, 
or in inducing more or less serious departures from 
the normal type of formation ; by which either actual 
disease may be induced, or what is far more likely, a 
tendency may be implanted in the organism which 
may lead to the degeneration of the dental organs by 
increased vulnerability ; or by the absence of certain 
of the normal and necessary structures composing 
the tooth, and the destruction of the dental organs 
from inherent defects in their formation. 

The influence of proper remedies upon the dis- 
eases of the hard tissues, is now one of the recognized 
facts in the surgery of the body at large. The 
same is no doubt true in the surgery of the dental 
organs, but this seems to have been strangely ne- 
glected. Why is it not fully as reasonable to hope 
for a renewed and restored nutrition in caries of the 
jaw, or in threatened conditions of the teeth, as it is 
to expect a regeneration of the long bones of the leg, 
or of the arm, after necrosis of these structures ? This 
is now a recognized occurrence ; cases are daily be- 
coming less rare in which the whole of the body of a 
long bone has been removed, and recovery has fol- 
lowed, with complete restoration of integrity and 
function of the parts involved. The bony structures 
have been regenerated, and the powers of the limb 
have been fully restored. 

If these regenerative processes can take place in 
the long bones of a distant extremity, it would seem 
certainly probable that similar restorative changes 



66 DENTAL PATHOLOGY. 

might occur in a part so highly vascularized and so 
susceptible to the action of remedial measures, as is 
the jaw ; and if in the jaw, then why not in the teeth? 
These organs would seem to be peculiarly adapted 
for the beneficial action of general treatment. They 
are buried to more than half their volume in a vas- 
cular and highly vitalized structure, from which they 
are supplied with numerous and important channels 
of nutrient character, which penetrate every portion 
of their substance ; the interior of the organ is pro- 
vided with a pulp consisting of connective tissue, and 
containing a large number of nerves and blood-ves- 
sels, which ramify through the entire tooth structure, 
and furnish the means of ample and rapid metamor- 
phosis of tissue. How far the conditions here sug- 
gested would prove true in actual practice is not yet 
settled, but certainly no more fertile field for original 
investigation could be presented to the careful and 
observing dentist, than the one here mentioned, and 
no more useful subject could occupy the leisure of a 
devoted student than the elucidation of this obscure 
point in the management of certain forms of disease 
in the dental organs. 



PART III. 



CHAPTER VHP 

RELATION OF THE DIGESTIVE OKGANS TO DISEASES 
OF THE MOUTH AND TEETH. 

Of all the causative agents in the production of 
disease of the dental organs, none are more frequent 
or more disastrous than those which depend on dis- 
turbances of the function of digestion and that of 
assimilation. These derangements may be of very 
varying character, and may be located in any portion 
of the digestive tract. Both sexes are alike subject 
to these disorders, and no age or condition is free 
from their pernicious influence. Their operation 
may at times be noticed in the infant of a few hours, 
or it may be observed in the aged. Too little atten- 
tion is directed to this great class of affections as 
factors in the production of disease of the dental 
structures, and too often the destruction of the teeth 
is not recognized until these delicate and necessary 
organs are lost, or too far decayed to admit of inte- 
gral or artificial restoration. Few appreciate the 
importance of the diseases embraced under this head, 
least of all the patients themselves, who are apt 
to imagine that, because this class of maladies is 
rarely of itself directly the cause of death, they are, 
67 



oS DENTAL PATHOLOGY. 

therefore, of trifling consequence. It is not to be 
supposed that a perpetual mal-assimilation, a con- 
stant defect of nutrition, can be devoid of detrimental 
effect upon all the tissues and organs of the body, or 
upon the proper exercise of their functions. 

In children who from any cause are badly or 
insufficiently nourished, there is always a marked 
retardation in the development of all the organs. 
The face wears a pinched and wrinkled appearance, 
the color of the skin is either a transparent, dead 
white, or it is tinged to a greater or less degree with 
yellow. The hair and skin are often noticeably 
diseased, and the natural orifices of the body are 
frequently the seat of ulceration, or otherwise dis- 
eased. The degree of emaciation which ensues is 
often astonishing. The bones remain soft and flexi- 
ble, and should the child be able to stand or walk, 
the legs often become curved from bending of the 
long bones; the chest is misshapen from the distor- 
tion of the ribs, and the form of the patient is often 
greatly disfigured. In eases which occur at a time 
previous to the eruption of the deciduous teeth, their 
appearance is often delayed, or they erupt very slowly 
and irregularly. Frequently a year is required for 
the advent of the central incisors, which normally 
a i ij >ear at about the seventh month. The other teeth 
of the first dentition are correspondingly slow to 
make their appearance, and occasionally the first 
dentition is imperfect, from a permanent absence of 
one or more of the teeth belonging to that set. 

A child born with a load of inherited disease, 
insufficiently nourished both in quality and quan- 



DIGESTIVE ORGANS AND THE TEETH. 69 

tity of food, can hardly be expected to furnish perfect 
and durable structures in any of the tissues, and per- 
haps least of all in the hard tissues. When the teeth 
finally appear, they are often seen to be small, puny 
organs, imperfect and defective in their structure, 
and especially in their enamel covering. Such teeth 
are badly nourished, and, in addition to this, they 
are continually subjected to the injurious action of 
the abnormal fluids of a sick and weakened system. 
They often begin a retrograde metamorphosis before 
they have reached their ultimate growth or normal 
proportion. The enamel begins to crumble at the 
top or upon the sides of the teeth ; the sour and acrid 
secretions of the mouth and the eructations from the 
stomach attack the imperfect dental substance ; it 
becomes darker in color and offensive in odor, and 
undergoes a rapid decay which is often entirely free 
from pain, owing to a progressive atrophy of the 
nervous structures in the teeth, which has preceded 
the decay that was advancing from the outside. 
This condition of the teeth may react upon the sys- 
tem, both from the increased difficulty attending 
mastication, as well as from the continual presence 
of a mass of disease in the mouth, and thus still 
further impair the condition of the patient. Parti- 
cles of food are retained within the spaces and cavi- 
ties of the defective teeth, and still further corrode 
them. The saliva becomes acrid, the breath offen- 
sive, and the fetor from the filthy and diseased mouth 
forms still another hindrance to the vitality of the 
patient. 

If the patient who is the subject of this condition — 



70 DENTAL PATHOLOGY. 

usually a child — be well cared for, the strictest atten- 
tion being given to the removal of the various mor- 
bid conditions which exist in such a case, and suitable 
measures be observed for the restriction of the abnor- 
mal conditions of the system at large, the destruction 
of the primary denture may not only be checked, 
but, what is of vastly greater importance, the erup- 
tion of the permanent teeth may take place at the 
proper time, and in the natural order. The teeth 
themselves may prove to be solid and perfect in 
every particular, and may betray no sign of the pre- 
vious condition of the system, or of the fate of the 
first denture; nor manifest any tendency to the dis- 
eases of the deciduous organs. 

As long as the food of the infant consists solely of 
mother's milk, there is little danger to be appre- 
hended either to the general health of the child, or 
to the integrity of the dental structures. This is 
owing to two principal reasons: First, the number 
of teeth which make their appearance during the 
period of milk-feeding are comparatively very few, 
and, second, the disordered conditions due to imper- 
fect digestion are rare, during the period while the 
diet of the child is composed strictly of mother's 
milk. This aliment is naturally better adapted to 
the requirements of the growing child, than any 
artificial food could possibly be, and at the same 
time is more easily borne by the child's stomach than 
any substitute which could be adopted in its place. 
One undoubted reason of the greater extent of den- 
tal disease among the children of to-day than in 
those of a generation ago, is the fashion of feeding 



DIGESTIVE ORGANS AND THE TEETH. 71 

them upon some other food than mother's milk ; — 
which is unhappily but too extensively disseminated 
in our country — thus deranging the vital processes of 
infantile growth by a wrong system of nourishment, 
to the permanent detriment of the child's health ; 
and frequently also to the destruction of the decid- 
uous teeth. The dental profession is now in a posi- 
tion to accomplish a great deal of good by impress- 
ing upon the public the importance of the natural 
aliment for the young child, at that time of all others 
when this is most important, that is, at that time in 
which the dental alimentary structures are being- 
developed, and when the tissues are most susceptible 
to any degenerative changes. 

The manner in which destructive processes are 
induced by infantile indigestion, is twofold : First 
there is a diminution in the quantity of nutritive 
material obtained by the system for its manifold re- 
quirements in building the many varying structures 
which are constantly being developed, and thus 
their integrity is continually being undermined by 
the lack of sustenance for their perfect formation ; 
so that the faulty tissues are always liable to break 
down easily, and thus by their necrosis and conse- 
quent suppuration to add to the already existing 
trouble. We often meet cases of this character in 
which there is suppuration of the cervical glands 
with continuous discharge for months, or where 
there is an offensive and persistent running from the 
ears, and frequently there is coincident disease of the 
mucous membrane of the eyes, or other portions of 
the delicate superficial or visceral organs of the body. 



72 DENTAL PATHOLOGY. 

Often the joints are affected, the limbs are dis- 
torted, there is infirmity and often persistent dis- 
ability, and the patient's whole system is debilitated 
and rendered vulnerable to the slightest accidental 
influences, and suffers from the mildest forms of 
physical exposure. We could hardly expect to find 
a healthy and vigorous condition of the teeth in a 
child with such a condition of bodily health as that 
described. In actual practice the reverse is generally 
observed. The teeth will be found small, usually 
either crowded irregularly together, or separated by 
considerable intervals from each other, perhaps 
diminished in number, often imperfect in character, 
sometimes the incisors being misshapen and irregu- 
lar, or the individual teeth of the denture may be 
protruded from the jaw at any angle from their 
proper direction, and thus often cause great distor- 
tion of the features, and sometimes actual suffering. 
The congenital irregularity of the teeth is the occa- 
sion of the fancied resemblance of the human 
denture to that of certain animals, as the cat, dog, 
etc., and we often hear of this form of defective de- 
velopment in the guise of cat-teeth, dog-teeth, wolf- 
teeth, etc. 

It might be difficult to account for the varying 
forms of denture observed in children, could we not 
trace the origin of these appearances to something in 
the manner of life and condition of health of the 
patient during the early period of dental develop- 
ment; or, indeed, perhaps before the birth of the 
child. It is an established fact thattheintra-uterine 
l^eriod is often the time when certain faults of con- 



DIGESTIVE ORGANS AND THE TEETH. 73 

straction or location of organs occur, and from 
which they are perpetuated. Examination of the 
individual teeth in such cases often reveals fissures 
of the enamel, due not to decay, but to deficiency in 
original formation; or actual spaces may exist in 
which it is almost entirely absent ; or we may find a 
minute orifice upon some portion of the presenting 
surface of the tooth, which leads to a canal in the 
tissues of the organ communicating with a congeni- 
tal cavity in the deeper structures of the tooth ; or 
in rare cases the canal so formed may be continuous 
with the pulp-cavity, thus forming a fistulous opening 
to the root of the tooth. It is unnecessary to say 
that teeth which are the subjects of an organic de- 
fect such as is here described, are more than usually 
subject to degenerative changes, and very early fall 
a prey to caries ; or are extracted at a comparatively 
early age, on account of the pain engendered in them 
by the progress of the diseased condition. Relief is 
not always secured even by extraction of the offend- 
ing tooth, on account of the liability of the bony 
tissues around the socket of the diseased tooth to 
take on morbid action, which sometimes leads to 
necrosis of the bone and the ulceration of the super- 
ficial tissues, with the formation of one or more 
sinuses extending from the surface of the skin or the 
mucous membrane to the seat of the disease in the 
bone, or even to a greater depth than the vicinity of 
the exposed bone. From the openings thus formed 
there is a more or less constant discharge of puru- 
lent matter, which may persist for months or even 
years, with the separation and discharge of frag- 



74 DENTAL PATHOLOGY. 

ments of dead bone, and sometimes more or less 
hemorrhage from the deeper parts of the sinus. 

This condition may finally terminate by the 
gradual healing of the sinus, with the formation of 
a deep cicatrix which unites the external skin to the 
bone ; or it may continue to spread along and within 
the bone, until a great part of the osseous tissues of 
the affected side, from the ramus of the jaw to the 
symphysis, when the lower jaw is the seat of the dis- 
ease, or an extensive part of the superior maxilla, 
has become necrotic and has been cast off by sup- 
puration. In these cases the remaining teeth 
usually become gradually loosened, from the soften- 
ing of the bony tissue containing them, and either 
require extraction at the hands of the dentist, or 
they are extruded from the jaw, owing to the lack 
of sufficient support from the hard tissues to retain 
them in their natural position. 

When n to very has occurred, if this is possible, the 
resulting appearance of the jaw is that of a deformed 
and misshapen feature, and it is usually, or at 
least often, necessary to provide an artificial denture 
for that portion of the jaw which was the seat of the 
diseased action. 

The second way in which the disorders of the 
digestive system may affect the integrity of the teeth, 
is from the liability which such a condition of the 
alimentary system induces to the regurgitation of 
portions of the food from the stomach into the 
mouth. This is a frequent accompaniment of gas- 
tric disturbance, and is a symptom of considerable 
gravity in such cases. The vomiting usually occurs 



DIGESTIVE ORGANS AND THE TEETH. YD 

at a period some time after the ingestion of the food, 
and at a time in the process of digestion when the 
contents of the stomach have undergone an acid fer- 
mentation, in which new and unnatural products of 
acrid character have been formed. The presence of 
these strongly acid eructations in the mouth and in 
contact with the teeth, is then a matter of frequent 
occurrence, which no amount of care can wholly 
obviate. 

The existence of this condition is not confined to 
infancy, but may occur at any age, and from many 
causes. Sometimes it consists only in an occasional 
regurgitation of a small amount of fluid from the 
stomach, at some period after a meal, and may then 
be due to the ingestion of some substance of an indi- 
gestible character, or to the temporary disturbance 
of the process of gastric digestion from some other 
temporary and local cause. Oftener it is, however, 
the result of long-existing and chronic disturbance 
of the digestive function, and there is a regular and 
considerable degree of regurgitation of the contents 
of the stomach. The vomited matter has a strongly 
acid reaction, and is frequently of fluid consistency 
and of mucous character. The normal gastric diges- 
tion will be found to have been replaced by an acid 
fermentation of the food, with the production of lactic 
and butyric acids. There is a total suspension of the 
natural process of digestion. 

When fluid of this character is violently regurgi- 
tated from the stomach into the mouth, the teeth are 
necessarily bathed in it, and are constantly subjected 
to any chemical or other action which the presence 



76 DENTAL PATHOLOGY. 

of a fluid of this character may excite. It is an 
established fact that chemical action at once com- 
mences between the acid fluid from the stomach, and 
the tissues of the teeth, which slowly, but none the 
less surely, erodes the enamel by its solvent action, 
and finally penetrates this layer of the dental cover- 
ings, when it extends its ravages more rapidly into 
the unprotected tissues beneath. The destructive 
action of the disordered gastric fluids upon the teeth 
may advance with such rapidity that a disturbance of 
the digestive function, of only limited duration, may 
be followed by the impairment or loss of all or nearly 
all the denture. This effect may be produced in rela- 
tion to either the temporary or the permanent struc- 
tures. 

The accumulation of foreign matter of any kind 
upon or between the teeth, where it may remain 
for some time without being disturbed, is another 
source of danger to the teeth in any condition of the 
system in which there is eructation of acid matter 
from the stomach. 

Particles of food are prone to accumulate around 
or between the teeth, unless great care is exercised to 
avoid it, and these collections in obscure parts of the 
denture are often the starting point of extensive 
decay. The spaces between the teeth are especially 
liable to retain masses of foreign material, and are 
the favorite seat of the destructive processes due to 
acrid regurgitation from the stomach. Under these 
circumstances the enamel is observed to become 
white and lustreless, the texture becomes brittle and 
friable, the animal matter disappears, and the super- 



DIGESTIVE ORGANS AND THE TEETH. 77 

ficial layers of the tooth structure become changed 
to a crumbling mass which may be removed by any 
slight touch. At times the process of destruction is 
so rapid, and the change in the tissues so extensive, 
that the tooth breaks squarely off, leaving a rough 
and ragged fracture, which wounds the lips and 
tongue, and often causes, ulceration of the neighbor- 
ing parts. The teeth which are the seat of this dis- 
ease are often exquisitely painful, owing to the fact 
that the decay of the hard portions of the body of the 
tooth finally reaches the dental canal. The struc- 
tures of the pulp then take on inflammatory changes, 
and the tooth becomes the seat of acute pain which 
often affects not only the tooth originally diseased, 
but extends to neighboring sound teeth. 



78 DENTAL PATHOLOGY. 



CHAPTER IX. 

BACTERIA AND THEIR ACTION IN DISORDERS OF THE 
TEETH. 

In this connection may properly be mentioned that 
class of diseases of the teeth which is supposed to 
be due to the presence and action of the various ani- 
mal and vegetable parasites, principally the latter. 
Certain forms of low organic life of parasitic charac- 
ter are uniformly found in the mouth, even in a state 
of health, and are not excluded by any degree of 
care of the teeth ; but these natural and constant 
forms are not thought to be the cause of disease of 
the oral organs under ordinary conditions. When 
fermentative changes are going on in the stomach, 
however, we find that new forms of bacterial organ- 
isms at once appear in the mouth, as the companion 
of the disordered digestion, and these new forms of 
bacteria are associated with the putrefactive and fer- 
mentative character of the processes going on in the 
stomach. They are supposed to be principally of 
vegetable nature, and are the regular and associated 
accompaniments of fermentative decomposition. 
They are invariably found in the mouth when this 
condition exists in the stomach, that is, of course, if 
regurgitation of the fermented matters takes place 
into the mouth. These minute organisms are thought 
by many observers to be the cause and origin of the 
carious degeneration of the teeth in cases such as 



ACTION OF BACTERIA ON TEETH. 79 

have been described above. They are believed to 
propagate rapidly in the interstices between neigh- 
boring teeth, and by their increased numbers to 
invade the minute canals of the teeth, — the dental 
canaliculi, — entering from the surface of the tooth 
with which they lie in contact, or from the cavity in 
which they may have become lodged, and where they 
have remained undisturbed for a longer or a shorter 
period. While it is an undisputed fact that various 
parasitic growths are often, indeed, almost always, 
found in association with advancing caries, it is still 
an open question whether caries is necessarily, or in 
any way frequently, the direct result of bacterial 
invasion, or connected with the presence of any of 
the common forms of the lower organisms. 

Authorities are not wanting who enumerate and 
describe the parasitic diseases of the mouth with a 
degree of assurance and positiveness not warranted 
by our present knowledge upon this subject. The 
recent increased importance ascribed to the various 
forms of bacterial growth in the production of many 
of the diseases of the body at large, has made us 
acquainted with many facts in relation to these 
bodies which were not before known, and this should 
make us more than ever circumspect in our asser- 
tions in regard to the degree of importance to be 
ascribed to them in the production of disorders of the 
nutrition, or in the degenerations of the dental 
tissues. Certain of the bacterial forms are constantly 
to be found in every mouth, and are not known to 
do the slightest harm. Thus, a careful microscopic 
examination of the interior of almost any mouth 



DENTAL PATHOLOGY. 

will disclose the pres< nee oi a certain parasite, called 
li ptothrix buccalis," in some stage of i s devel- 
opment. Ii is found in health as well as in disease. 
md in clean mouths as well as in those which 
are filthy, it is nol fastidious as to the color, sex or 
condition oi mperature seem 

to have littL . for the conditions of heal 

listure within the mouth are much the same 
the outside climatic 
-tant inhabitant 
\\\rv the mosl scrupulous 
-.( ill ;n night it may be found in 
in the morning; ii will develop under 
in almost any condi- 
y temperature with impunity 
died i" the mouth without injuring 
ud it will withstand any 
the circumstances 
indeed appear strange it' 
i upon and around all 
■ . It is of very small 
minute than the 
. and have the power of attaching 
•stance with 
;. What wonder, then, if 
a the outside of the teeth, in 
the Hi - found between neighboring 

. the filthy and decomposing sub- 
3 which ar« 1 in connection with 

dental All this in no way. however, proves 

thai ti 

and destroying by their 



ACTION OF BACTERIA ON TEETH. 81 

unaided activity the most dense and compact, as well 
as the most resistant tissue of the human body. That 
their presence may accelerate the decay of the dental 
structures, and in this way be harmful, is not to be 
denied, but their importance in this direction has 
undoubtedly been greatly over-estimated. 

There is another form of bacterium which is some- 
times found in the mouth and about the teeth in 
some forms of disease of these structures. This or- 
ganism is far better known than the Leptothrix, and, 
unlike it, may be found in all parts of the body 
wherever the conditions are favorable for its devel- 
opment. It is always associated with the process of 
decomposition, and is regarded as indicative of that 
condition. It is observed in the form of small, mod- 
erately thick staves, which may be attached to one 
another to make small chains, but more generally 
are found singly in the field of the microscope. They 
are thought to be also of vegetable origin, and are 
supposed to act as scavengers, by consuming the 
products of decomposition, or by destroying the 
virulency of these products by a process of oxida- 
tion, thus changing their chemical composition. 
Their vital activity is thought to diminish the injuri- 
ous nature of the decomposing substances in which 
they are found, and, finally, to render such matter 
harmless. The presence of this organism is looked 
upon as indicative of decomposition, and the de- 
tection of the bacterium in the wounds of general 
surgery is always a reason for the most scrupulous 
and unremitting attention to the patient. In dental 
surgery the presence of this parasite in wounds has 



82 DENTAL PATHOLOGY. 

the same meaning as in the surgery of other parts 
of the bod}-. If found in a mass of debris lying 
between the teeth, it is an evidence of the putrid 
condition of the matter concealed there, which, of 
itself may inaugurate disease in or about the teeth. 
When they are found in the teeth as a part of the 
contents of a foul cavity, they prove only the filthy 
condition of the diseased spot; that is, they indicate 
not only that disease already exists in the place 
where they are found, but that chemical decompo- 
sition of the products of disease, or of the surround- 
ings, is there going on, thus establishing the most 
unfavorable conditions possible in proximity to a 
diseased part. It is proved that bacteria may pene- 
trate into any channels which open upon the surface 
where they are situated. They are often found at 
some distance from their original seat. Whether 
this migration is accomplished by voluntary effort, 
or by the unconscious and organic movements of 
the parasite, is not definitely established, but the fact 
remains that they possess the power of locomotion. 
Another way in which they may change their loca- 
tion is by the current of blood or lymph, or by the 
movements of any other tissues of the body into which 
they may have penetrated. The moving tissues of 
the animal body convey the bacteria from one point 
to another in a purely mechanical manner. This 
occurs far more frequently after injuries or operations 
upon the body at large than in the tissues of the 
mouth, but no doubt it is often an active factor in 
the spread or direction of certain of the diseases of 
the mouth which are accompanied by suppuration, 



ACTION OF BACTERIA ON TEKTH. S3 

and more especially those of phagedenic character. 
Such disorders are at times observed to rapidly 
extend from one structure to another, so that the 
entire denture of one jaw may fall a prey to a disease 
which is propagated from one portion of the jaw to 
another by direct extension, until the entire alveolar 
structures are affected. In the various forms of 
necrosis of the jaw, it is quite the rule to find bac- 
teria in the pus and other products of the diseased 
process, and to find them in all parts where suppu- 
ration has occurred, and for a period as long as pus 
is discharged from the diseased surfaces. No one, 
however, supposes that the necrosis is the result of 
the presence of bacteria, or is due in any way to their 
action, or that the disease is prolonged by their 
presence. They are regarded simply as an accom- 
paniment of a grave disease, and with the healing 
of the disease these parasitic organisms disappear ; 
to return only when conditions favorable for their 
development have again been established. 



84 DENTAL PATHOLOGY. 



CHAPTER X. 

DEFECTIVE EMBRYONIC DEVELOPMENT OF THE 
MAXILLARY STRUCTURES. 

The early history of the dental structures is 
shrouded in uncertainty. The study of the devel- , 
opment of the individual organs is attended by diffi- 
culties such as are not associated with the histological 
investigation of any other of the structures of the 
human body. The maxillary bones are among the 
earliest formations noticeable in theembryo, and the 
lower jaw is the first osseous tissue developed in the 
body. There can be but little doubt that the views 
prevailing among anatomists at present are in the 
main correct, and they certainly explain the relations 
and connections of the oral structures better than 
any others at present extant. The accepted opinions 
at the present time are something as follows: During 
the earliest stages of intra-uterine life, which natur- 
ally is the only period at which anatytical research 
could offer any prospect of reward, the tissues of the 
embryo are but partially formed, and in a state of 
imperfect construction. The rudiment of the supe- 
rior maxillary bone is observed at a date about the 
third week from conception. This primary structure 
is formed by the union of two of the early lateral 
projections of the embryonic body, called the thoracic 
arches, which are thrown out after the union of the 
germinal membranes. The superior arches are earlier 



DEFECTIVE EMBRYONIC DEVELOPMENT. 



85 



developed and join each other earlier than the infe- 
rior ones, and, consequently, the primitive superior 
maxillary is earlier in point of development than the 
inferior. The histological character of this early 
formation is very simple. It consists only of simple 
rounded or oblong cells, the so-called "embryonic 
connective tissue," and presents the greatest similarity 
to the granulation tissue found in the process of repair 




(a) Macerated left half of the inferior maxillary arch, from a fcetus, at the 
seventh month of pregnancy. View from the lingual side. The partitions 
or septa for the incisors are partially formed ; the facial wall of the canine 
tooth still presents a gap. The septa for the milk molars are indicated by 
slight ridges ; that for the first permanent molar is already perceptible 
toward the coronoid process. Natural size, (b) Left half of the inferior 
maxillary arch, from a new-born child ; decalcified by means of dilute 
hydrochloric acid, and bisected by an incision corresponding with its curve. 
The incised surface of the outer half is exposed to view ; the dental sac and 
contents are removed. The separate walls for the dental sacs of the milk 
teeth are completely developed; the septum for the first permanent molar is 
seen to be partially developed within the coronoid process. Natural size. 



of wounds in adult life. As yet no blood vessels or 
nerves are observed in the part ; the growth of the 
organ takes place simply by means of active pro- 
liferation of the round cells above mentioned, in the 
arches and in their vicinity. The inferior maxilla 
is somewhat later in its development from the two 
primary arches than is the superior, but after its 



8G DENTAL PATHOLOGY. 

fusion it advances more rapidly than the upper, so 
that at length it is the first bone in the animal body 
to undergo the process of ossification. At the time 
of birth the lower jaw is deemed the strongest bone 
in the body, and in some cases of difficult labor, in 
which the operation of version becomes necessary, 
the birth of the head of the infant becomes a matter 
of great importance, and, indeed, is sometimes almost 
impossible. In such cases, the most favorable point 
for manual traction is the arch of the lower jaw at 
the point of union of the two lateral halves. At this 
point, the most forcible tractile power which can be 
safely applied may be exercised without the produc- 
tion of injury either to the jaw or to the child In 
many cases of this kind, in which the child is known 
to be dead, violent traction has often been steadily 
exerted at this point through a considerable time, 
and it is rarely the case that the jaw is fractured or 
otherwise injured. When we remember how fre- 
quently and how easily the other bony structures 
are injured during birth, it may well seem that the 
maxillary bones are endowed with an unusual degree 
of resistance at this early period. 

The exact period at which ossification of the max- 
illa ry bones takes place is not certainly known, but 
a true bony structure is observed soon after the junc- 
tion of the two lateral halves of the jaw, and in the 
upper jaw this seems to proceed from four centres on 
each side, each centre of ossification spreading until 
it joins the other osseous masses, except in the case 
of the centres of ossification for the intermaxillary 
bone on each side containing the incisor teeth, which 



DEFECTIVE EMBRYONIC DEVELOPMENT. 87 

is joined to the rest of the bone by a well-defined 
suture on either side. The early formation and 
solidification of this bone is one of the chief factors 
in the formation of the face ; the general outline of 
the features and the expression of the countenance 
depending more upon the shape and relations of the 
superior maxilla than upon any other bony tissue 
of the body. The malar bone, although a separate 
anatomical structure, may, in its relations to the 
formation and contour of the facial region, well be 
regarded in this connection as a part of the superior 
maxillary, as it corresponds closely to it in its time 
and manner of development. The absence or de- 
formity of either of these bones causes great disfig- 
urement and lasting deformity. At times, the process 
of ossification is retarded in some portion of this bone, 
particularly in the vicinity of the sutures between 
the various parts from which the superior maxillary 
is formed, so that a close approximation of the neigh- 
boring bones cannot occur, thus leaving a fissure 
between them of greater or less extent, which is 
recognized as the well-known condition of cleft, either 
of the soft palate alone; or, quite as frequently, it 
extends through a portion or the whole of the hard 
palate, often dividing the lip and extending into one 
or the other nostril, which is thus continuous with 
the oral cavity. When this is confined to the median 
suture, it presents a fissure running from behind to 
a greater or less distance forward toward the incisor 
teeth, in the place of the velum palati and of the 
suture naturally found in this location. Sometimes 
the fissure is quite limited in extent, and consists 



88 DENTAL PATHOLOGY. 

Fig. 12. 
Cuts Illustrating the Formation of Cleft-Palate.— After Prof. Albrecld. 

1 




(1) The superior maxillary body is formed by the union of the two superior 
maxillary bones and the intermaxillary bone. In its original development 
the intermaxillary bone is composed of four smaller bones, arising from four 
separate centres of ossification, and united to each other and to the body of 
the superior maxillary bones on each side by sutures. The bones and sutures 
have received the following names: — 

a, Internal intermaxillary— Endognathion , h, external intermaxillary— Mesog- 
nathion ; c, superior maxillary bone— Exognathion. 1, Inter-endognathic 
suture; 2, Eudo-mesognathic suture ; 3, Meso-exognathic suture. 




(2) The location of the teeth in the ordi- 
nary superior primary denture of the 
human mouth. The internal incisor 
is contained in the internal intermax- 
illary bone (endognathion). The ex- 
ternal incisor (precanine) is contained 
in the external intermaxillary 
(mesognathion). 



(3) The location of the incisor teeth in 
cleft-palate with three incisors on 
each side the median line. (Specimen 
in the collection of the Anatomo- 
Pathological Society of Brussels.) The 
internal intermaxillary bone (endog- 
nathion) contains two incisor teeth on 
each side the median line, the third 
incisor being contained in the external 
intermaxillary bone (mesognathion). 



DEFECTIVE EMBRYONIC DEVELOPMENT. S9 

only of a notch in the soft palate, which may be 
quite symmetrical, or may be more pronounced on 
one or the other side, with a more or less well- 
developed uvula depending from the other. In other 
cases the gap is very extensive, the roof of the mouth 
presenting a yawning chasm, through which the tur- 
binated bones may be seen, if they be in their proper 
location; the vomer, and in some cases even the 
ethmoid and the base of the skull, may thus become 
visible. In extreme cases there is often, if, indeed, 
not generally, a corresponding lack of union at the 
seat of the suture existing between the two maxil- 
lary bones and that portion of the upper jaw which 



In the cleft-palate with four incisors, the internal intermaxillary (endogna- 
thion), contains only one incisor tooth, while in the case of cleft-palate with six 
incisor teeth, the internal intermaxillary contains two incisor teeth. It becomes 
evident on reflection that the incisor tooth situated nearest to the median line, 
that is, the internal of the two incisors contained in the internal intermaxillary, 
is the homologue of the single tooth contained in the internal intermaxillary 
bone in cleft-palate with four incisor teeth. The tooth situated nearest to the 
symphysis between the two internal portions of the intermaxillary bones, the 
median suture, is called by Prof. Albrecht the parasymphysienne incisor tooth. 
The two parasymphysienne teeth contained in the cleft with four incisors are 
therefore homologues of the teeth contained in the normal milk denture The 
additional tooth contained in the internal maxillary bone, in cleft with six 
incisor teeth, and which is called the proparasymphysienne incisor, has no 
homologue in the ordinary human milk denture of cleft with four incisors. In 
the ordinary cleft with four incisors, the parasymphysienne incisor is the first 
incisor tooth. The precanine is the second incisor. In cleft with six incisors 
the parasymphysienne is the first incisor ; the precanine is the third incisor. 
The superior internal incisor, or the parasymphysienne, is in reality the first 
incisor. The external superior incisor tooth, or the second incisor, of the nor- 
mal denture, the superior precanine, is in reality the third incisor tooth. The real 
second superior incisor is no longer developed in the ordinary human denture, 
but in cases of cleft with six incisors this tooth reappears, and constitutes the 
second incisor of these cases. This reappearance is due to atavism, which is 
observed in many other respects in relation to the human body under certain 
conditions. In the cases of cleft with six teeth, the internal intermaxillary 
bone, the endognathion, carries the additional tooth, and the third, the pre- 
canine, is contained in the external intermaxillary bone (mesognathion). 



90 DENTAL PATHOLOGY. 

contains the incisor teeth, the primary intermaxil- 
lary bones, by which the front of the cleft is divided 
into two distinct fissures, like the two arms of a " Y," 
and the intermaxillary bone is then entirely free 
from any bony attachment to the rest of the maxil- 
lary structures. In this extreme condition of de- 
formity, the fragment of bone with the incisor teeth 
is often twisted into an abnormal shape, and is gen- 
erally crowded forward so that it protrudes' beneath 
the nose, producing a degree of disfigurement truly 
frightful to behold. The palatine surface of the small 
intermaxillary bone is sometimes turned directly 
outward, so that the contained teeth are projected 
forward and arc at all times exposed to view, the 
patienl not being able to cover them with the frag- 
ment of upper lip, which is all that usually exists in 
such cases, or, at least, the upper lip is relatively very 
much smaller than normal, and quite insufficient for 
protection of the misplaced teeth. 

In most if not in all these extreme cases there is a 
corresponding defect in the formation of the upper 
lip, so that a fissure is observed in the lip, which 
communicates with the nostril of one or the other 
side. This defect of the soft tissues then leaves the 
mouth always more or less open ; it is impossible for 
the patient to close the mouth against the ingress of 
air, or to retain fluids in that cavity. The same 
fissure also extends into the nose, as above stated, and 
thus the nostril of the affected side is continuous 
with the cavity of the mouth, from which it is impos- 
sible for the patient to separate it, as is ordinarily 
done in speaking or swallowing. The speech is 



DEFECTIVE EMBRYONIC DEVELOPMENT. 91 

seriously affected by the absence of a partition be- 
tween the mouth and the nose, and the person so 
affected has a peculiar and characteristic articula- 
tion, commonly described as " talking through the 
nose," which is caused by the patient's inability to 
shut off the nasal cavity from that of the mouth. 
Occasionally there are other defects of formation in 
the patient with cleft palate, due to the same gen- 
eral cause, that is, a lack of complete union of the 
lateral portions of the body in the median line. 
These defects are frequently situated in parts of the 
body not usually exposed to view, and often are of 
extensive character, and at times seriously interfere 
with the natural functions of the body. They are 
also occasionally of such a degree of gravity in their 
influence upon the organism, that attempts are made 
to remedy them by surgical measures. Upon the 
back, a deficiency is sometimes observed in the 
spinous processes and in the lateral masses of cer- 
tain of the vertebrse, producing the condition called 
" spina bifida," and is due to a lack of junction of 
the dorsal plates during intra-uterine existence. 
This condition is observed only during the earliest 
period of existence after birth, for it is very rarely 
the case that the infant so affected survives more 
than a day or two, and frequently expires immedi- 
ately. Other serious malformations or entire defects 
of important internal organs or parts may exist, 
which render it impossible for the processes of life 
to be sustained in so imperfect an organism. Oases 
of this character are fortunately not common, and 
when observed they represent the extreme degrees 



92 



DENTAL PATHOLOGY. 



of lack of union of the visceral plates during em- 
bryonic life. 

From the preceding it will be seen that in many 




Palatine view of the skeleton of tbe superior maxillary body of a man, showing 

Pa complet r«ni ateral cleft of the righl side The plate shows indications of the 

sutures between the m-imarv elements of the intermaxillary bone, and the 

alveolar process "is divSed at the seat of the meso-endognathic suture on the 

right side.— After Prof. Albrechl. 



of the cases of deficiency or of abnormal arrange- 
ment of the dental organs, this is not wholly a 
local process, confined to one special portion of the 



DEFECTIVE EMBRYONIC DEVELOPMENT. yo 

animal organism, but that it is related to a defect in 
the constructive force of the entire body, and may 
find expression in other parts of the human frame 
as well as in the mouth and face. 

A careful study of the exact extent and of the re- 
lations of the deviations of the animal body will 
often discover deformities of one or another part due 
to deficient constructive force, by which the various 
tissues and organs are imperfectly formed or are 
insufficiently maintained ; the result of which is a 
greater or less disturbance in the normal functions 
of the parts affected, or of the entire organism. In 
cases in which a lesion of this character is detected 
in the mouth, an effort should be made to ascertain 
if this is the only defect of development, or if there 
be not other conditions of imperfect construction of 
the organs in other parts of the frame. A separate 
notebook devoted to the observation and record of 
deformities, with drawings and descriptions of the 
same, and accompanied by as much information 
concerning the appearances and habits of the indi- 
vidual as can be obtained, would form a valuable 
contribution to the study of the great and. interest- 
ing subject of the congenital or, more properly 
speaking, the embryonic defects of the animal body. 
We shall revert to this subject again at more length 
in that part of our study in which we take up those 
diseases associated with the malformations of the 
oral apparatus. 



94 DENTAL PATHOLOGY. 



CHAPTER XL 

DEFECTIVE DEVELOPMENT CONTINUED. 

Defects of formation are not so frequently observed 
in the lower jaw as in the upper, and are usually 
limited to more narrow deviations from the nor- 
mal. One of the more common varieties of mal- 
formation in this part of the oral apparatus consists 
in a condition observed in certain cases, in which 
the jaw is complete in shape and perfect in form, but 
is diminutive in size in relation to the other organs 
of the body. Occasionally, a variation in the 
arrangement of the teeth occurs, which may be due 
to some abnormal condition affecting the dental 
germs, and not the tissues of the jaw itself. Of these 
we shall speak in another place. The most striking 
anomaly in relation to the lower jaw is that which is 
sometimes observed in so-called " strumous " chil- 
dren, and which consists in the persistence of an 
infantile condition of the inferior maxilla in adult 
life. At the time of birth, the jaw is normally de- 
veloped, and corresponds with the coincident devel- 
opment of the other bodily organs, but while the 
other structures of the infant's body increase in size 
and strength, the tissues of the jaw do not grow after 
this period, but preserve their puny condition. For 
some reason not at present known, the formative 
energy in this bone seems to be confined to the sim- 
ple reproduction of the previously existing structure, 



DEFECTIVE EMBRYONIC DEVELOPMENT. 95 

while the organic impulse toward a natural increase 
in volume and power, proportionate to the rest of 
the body seems to have been wholly obliterated. The 
most marked case of this condition which has thus 
far fallen under the observation of the writer is that 
of a young man seen some years ago. The patient 
comes from a strong and vigorous family, is one of 
several children, some of whom are younger than 
himself. He considers himself perfectly well in all 
the ordinary acceptance of that term, does a thriving 
business in a small way, and apparently enjoys life 
quite as much as most people. He was 22 years of 
age at the time these notes were made, and was 
rather short in stature, very slight in build ; the limbs 
and extremities are small, the head in general of 
relatively normal size for his bodily development. 
The eyes are bright, the temperament lively and 
cheerful, and the general condition of the patient is 
one of comfort and happiness. The upper jaw is of 
normal size. The teeth have to some extent been 
removed by extraction, and are inclined to carious 
degeneration, so far as they are retained in the mouth. 
Several of the remaining teeth of the upper jaw are 
neatly filled with gold. They are smaller than 
usual, and somewhat deformed and irregular. The 
alveolar process and gum seem to be in a fairly nor- 
mal condition. The chin and lower lip recede very 
markedly from the position usually occupied by 
these parts, and lie in such a plane that a line ex- 
tending from the cutting edges of the incisors to the 
hyoid bone would present very nearly the outline of 
the lower lip and the chin. The appearance of the 



96 DENTAL PATHOLOGY. 

face is as if a clean slice had been removed, com- 
mencing at the level of the upper lip, and reaching 
to the hyoid bone, taking the soft parts and the 
bones, teeth and glands, and all other structures 
smoothly and evenly to the line of the cut surface 
above described. The skin is smooth and presents 
no cicatrix or deformity. There was hardly any 
power of opening the mouth or of closing it, and the 
speech was seriously interfered with, the pronuncia- 
tion was very defective, from the inability to properly 
manipulate the organs of articulation within the 
mouth, and the hindrance in the resonance of the 
vocal sounds. The tongue could be protruded only 
partially, owing to the small size of the oral aper- 
ture. 

The tongue was small, but otherwise healthy, the 
glandular and nervous apparatus accorded to this 
organ appeared to be in normal condition, the sense 
of taste was as well developed as is the case in 
healthy individuals. The lower lip cannot be de- 
li iv-i'i I by voluntary effort of the patient, the lower 
jaw cannot be seen unless the finger is employed to 
depress the lip. The lower teeth are small, mis- 
placed and misshapen, some have been extracted to 
enlarge the opening into the mouth, and those which 
remain are in a line nearly transverse to the direc- 
tion of the tongue, that is, nearly in a direction from 
one glenoid cavity to the other. That part of the 
lower jaw embraced between the condyle and the 
angle on each side seems to have grown somewhat 
since birth, but the part between the two rami seems 
to have remained in the same condition, as far as 



DEFECTIVE EMBRYONIC DEVELOPMENT. 97 

length is concerned, as it possessed at birth, though 
it is probably somewhat thicker, and has undergone 
ossification, so as to support the teeth which have 
been from time to time erupted from it. The finger 
introduced into the mouth feels the diminutive jaw- 
bone extending directly across the floor of the 
mouth, slightly depressed in its central part, an 
effect no doubt produced by the continuous depress- 
ing action of the tongue. The jaw and its remaining 
teeth have the tendency to shut up within the out- 
line of the upper jaw, and this would really take 
place except for the volume of the tongue and the 
bulk of the muscles on either side. 

The retreating position of the lower jaw with the 
soft parts, causes the alveolar process of the superior 
maxillary bone, with the incisors and canine teeth of 
both sides, to appear very prominent. They are 
without any protection in front and below, so that 
they are uncovered and exposed to sight all the time. 
Mastication is impossible, and the patient is obliged 
to live entirely on soft foods, which are sucked into 
the mouth through the half-opened jaws, and swal- 
lowed. Drinking is a serious operation for this 
young man, and it is needless to say that he is un- 
questionably temperate in this direction. The body 
generally is tolerably well nourished, and the patient 
thinks himself as well as young men in general, 
though he admits that he " always takes good care of 
himself." The study of the relation of the deformity 
in this case to the development of the higher in- 
stincts is both interesting and instructive. This 
patient, though arrived at man's estate, is decidedly 



98 DENTAL PATHOLOGY. 

youthful, not to say childish, in respect to the exist- 
ence of the powers and capacities of manhood. The 
voice is high in pitch, as before puberty, the tone is 
sharp and shrill. There is no sign of whiskers or 
mustache upon the face, there is no hair in the 
axillary region. The pubes are free from hair and 
soft. The appearance of the genital apparatus is 
that of complete apathy. The penis is small, the 
testicles almost rudimentary. He finds in the society 
of the opposite sex only that pleasure which a child 
knows, and is not inclined to cultivate female 
acquaintance. The whole picture of his demeanor 
and manners is that of the most simple and un- 
guiled innocence, and it is quite probable that this 
remarkable individual will run the gauntlet of 
temptation in this sinful world and take no defile- 
ment. 

That the absence of the higher organic and moral 
instincts in this case is associated with the immature 
or unripe condition in which the whole system has 
remained, seems to me to be a settled fact, and is 
made further interesting as a confirmation of the 
observation of Charles Darwin, that in any species, 
a weak or imperfect member, or in a cross between 
two species, the mongrel offspring is either too feeble 
to arrive at maturity, or if it should survive to reach 
adult age, it is not gifted with an exalted degree of 
reproductive instinct, and thus is less liable to pro- 
long its degenerated race than the healthy members 
are, so that the tendency is toward the extinction of 
the weak and frail in all classes of the lower ani- 



DEFECTIVE EMBRYONIC DEVELOPMENT. 99 

mals. This natural process of weeding out the poor 
and unprofitable members of any tribe of creatures 
is the foundation stone of the great theory of " natu- 
ral selection " and of the " survival of the fittest." 
In the human race, however, unfortunately this rule 
of limitation of vigor does not hold good to any 
such degree as in the members of the lower tribes. 



100 DENTAL PATHOLOGY. 



CHAPTER XII. 

HISTOLOGICAL DEVELOPMENT OF THE TEETH. 

The development of the teeth both in the human 
subject, as well as in the lower animals, has been the 
subject of much patient study on the part of good 
observers during many years, and each succeeding 
year records new discoveries and fresh triumphs in 
this obscure domain of histological investigation. 
The conclusions to which the researches of different 
savants have led, are still vague and uncertain, and 
often their deductions are doubtless erroneous and 
misleading. The generally received opinion is, that 
at a period about six weeks after conception has 
taken place, the alveolar arch and the surrounding 
parts have been to some extent moulded and shaped 
by the junction of the primitive embryonic arches, 
and are clothed by a delicate membranous covering 
which occupies the place of the mucous membrane in 
the fully developed body. At first, this delicate cov- 
ering is quite smooth and is evenly rounded, giving 
no indications of any further changes in its shape or 
relations, but gradually a minute depression or 
groove appears in its surface, which becomes more 
strongly marked, first, in the molar region of the 
upper jaw, and at a little later period in the lower 
jaw. In the bottom of this groove may soon be ob- 
served certain small elevations corresponding in 
number and arrangement to the deciduous teeth. 



DEVELOPMENT OF THE TEETH. 101 

These are the first traces of dental organs, and are 
the rudimentary tooth germs. They are for a time 
simple papillse, but soon the membrane about them 
begins to grow upward, and at the same time toward 
the papillae, so that the tooth germ is gradually 
buried under the encroachment of the membrane 
about it, and, finally, it is no more upon the surface 
of the membrane, but is enclosed in its substance. 
The tooth was then supposed to be gradually devel- 
oped in some unknown manner from this buried 
papilla, and finally to be protruded from the gum at 
a period from four to eight months after birth. The 
recent studies of men like Waldener, His, and Koel- 
liker have thrown-much light upon the hidden pro- 
cesses of the formative period of the teeth, and 
explain in a more satisfactory way, because in a 
more reasonable way, the structural development of 
these parts. I will here take the opportunity to say, 
that much of the ground in this domain of histolo- 
gical study has recently been most carefully and 
thoroughly gone over by Prof. Andrews, of this Col- 
lege, than whom I do not know a more conscientious 
and diligent observer, and his conclusions in all 
essential points confirm those of the authorities I 
have mentioned above. Prof. Andrews' enthusiasm 
for his profession, his experience in the use of the 
microscope, and his carefully trained eye in minute 
distinctions of color and form render his deductions 
in embryological histology of exceptional worth, and 
have added much to the value of the facts already 
composing our fund of positive information by lend- 
ing assurance of their correctness. 



102 



DENTAL PATHOLOGY. 



Starting from the period when the embryonic 
arches have approached each other and have united 
upon the medial line to form the primary maxillary 
structure, and the development upon its surface of 
the smooth membranous expansion, later researches 




A FOLLICLE OF MITiU'S CF.LLS EXTENDING FROM THE DENTAL RIDGE TO THE 

ENAMEL GERMS OF THE MILK AND PERMANENT TEETH; FROM A 

HUMAN EMBRYO OF THREE MONTHS' GROWTH. 

The cells of the mucous layer of epithelium clip down into the substance from 
the dental groove (a) of an incisor of the lower jaw, and resemble, somewhat, 
a tubular gland with lateral oilshoots At about the middle of the follicle, 
which is lined throughout with cylindrical cells, it is connected by a trans- 
verse process (6) with the external epithelium of the enamel organ, the 
spongy layer of which is represented (c). The inferior closed portion of 
the follicle is the enamel germ of the permanent incisor tooth. Magnified 80 
diameters. 



show that the first indication of a tooth germ con- 
sists in a slight groove upon the surface of the mem- 
brane in the alveolar line, somewhat as before 
described. The subsequent processes, however, are 



DEVELOPMENT OF THE TEETH. 103 

entirely different from the course described by Good- 
sir, in the works usually consulted upon this point. 
At the period of the development of the tooth 
germs a papillary prolongation of the mucous layer 
is seen, which soon becomes much enlarged, so as to 
dip deeply into the submucosa, which consists at 
this time here simply of round-celled granulation 
tissue; such as is the medium of new formation 
and repair, in the healing of open wounds in the 
adult body. The papilla is connected by a narrow 
neck with the surface of the membrane, but its 





deeper extremity rapidly increases into a club-shaped 
mass of relatively dense tissue ; and soon there can 
be distinguished three distinct elements in its struc- 
ture. It becomes continuous from the molar region 
on one side to that of the other, curving somewhat 
toward the oral cavity at its free edge. This now is 
called the enamel germ (the club-shaped prolonga- 
tion into the tissues of the alveolar mass), and seems 
to be not like the connective tissue, but resembles 
epithelium, which has undergone a peculiar trans- 



104 DENTAL PATHOLOGY. 

formation in structure and in appearance. The 
Enamel Germ is absolutely the earliest discernible 
rudiment of the dental structures and is not to be 
confounded with the Enamel Organ to be spoken of 
further on. Indeed, some observers claim to have 
observed it as a prolongation into the substance of 
the rudimentary jaw at a period when the two lat- 
eral portions of the jaw were not yet united, and it is 
certai n that this feature of development may be easily 
demonstrated long before the appearance of anything 
like a papilla upon the dental ridge in the dental 
groove. At this time there is no indication of 
alveolar ridges. A little later we find papillary for- 
mation on the lower side of the epithelial body, 
which soon begins to press upon the lower surface of 
the enamel germ, and at the same time important 
changes are already going on within this body. The 
epithelium in its interior becomes gradually changed- 
into a softer, colloid-like substance, the layer next 
the wall becomes columnar, and both begin to change 
their location nearer to the surface of the mucous 
membrane before the advancing tooth papilla. The 
enamel germ has now materially changed its char- 
acter, and has become an organized viscus, and it is 
hereafter called the Enamel Organ. Beneath this is 
formed at this period a small elevation of the em- 
bryonic tissue, somewhat more dense than that in 
its neighborhood, which raises up the lower surface 
of the enamel organ like indenting a rubber ball by 
means of pressure upon one of its sides. This is the 
true Tooth Germ, or Zahn-papilla, and from it is to 
be constructed, in the further development of this 



DEVELOPMENT OF THE TEETH. 



105 



organ, the dentine, the pulp with its vessels and 
nerves, the cement and the peridental membrane. 
The enamel organ is at this time the more advanced 
in its structure, and seems to consist of a closed sack 
lined with columnar cells, containing in its cavity a 
mass of softened and plastic material from which 
the enamel is later elaborated in some way not at 
present understood, which is then deposited upon the 




apex of the tooth papilla like a thin, glistening flake, 
which gradually covers its whole surface. The 
growth of the pulp slowly presses the enamel organ 
more and more together, thus tending to obliterate 
its cavity, and in this way forming a conical cover- 
ing for the papilla which finally extends over its 
superior surface, and is called the Dental Cap, or the 



106 



DENTAL PATHOLOGY. 



Enamel Cap. When the enamel organ is thus far 
formed a small diverticulum is observed upon the 
median side of each tooth germ, which becomes 
gradually removed from the tooth germ into the sur- 




S.Vi.lTTAL SECTION' OF A LOWER JAW FROM THE EMBRYO OF A DOG, SHOWING 
AN INCISOR WITHIN ITS DENTAL SAC. 

(a) Facial lip of the dental ridge; (6) epithelium; (c) coriuni, with papiike in 
the dental ridge, and cavities of transversely divided vessels; (d) enamel 
germ of the permanent incisor containing an aggregation of epithelial 
cells; its connection with the enamel organ of the deciduous tooth does not 
appear in the section; (e) anterior, («') posterior, osseous lamella of the jaw 
with rounded summits; (/) completed enamel of the dental cap; in the 
section it is separated, somewhat, from the (g) layer of enamel cells; (h) 
retiform connective tissue of the dental sac ; (i) outer epithelium of the 
enamel organ completely investing the papilla? of the dental sac; (ft) spongy 
layer of the enamel organ; (/) completed dentine of the cap; (m) layer of 
dentinal cells; (n) dental pulp with wide vessels in its interior. Magnified 



DEVELOPMENT OF THE TEETH. 107 

rounding tissues, and is finally entirely separated 
from this organ and is found as a simple indepen- _ 
dent collection of the same cellular material in a 
space by itself. This is the rudiment of the Enamel 
Germ of the permanent tooth, which is an offshoot 
from the enamel organ of the deciduous teeth. The 
germ remains dormant for a time, where it has been 
deposited, and finally is developed into the structures 
of the permanent tooth in a manner similar to that 
in which the milk tooth was formed. The further 
progress of the tooth germ, its development into the 
form it is later to assume, its elevation toward the 
mucous membrane, and finally its eruption from the 
jaw will be familiar to all, from proper collateral 
studies, and it is not necessary that we should follow 
the subject into its minuter details here. 

In. the development of the teeth a very interesting 
feature to the student of comparative embryology is 
their similarity of origin and development with that 
of certain other structures, particularly the sebaceous 
glands and the hair follicles. Indeed, the epithelium 
of the embryo is one of the most highly dignified 
structures in its entire organization. Besides glands, 
hair and teeth, the whole of the brain and spinal 
cord is formed directly from the external covering of 
the embryo. The similarity of the germinal tissue 
from which these organs are constructed and the 
dissimilarity of the finished organs is also worthy of 
especial' notice. 



PART IV. 



CHAPTER XIII. 

PATHOLOGICAL CONDITIONS ASSOCIATED WITH THE 
SECOND DENTITION. 

Among the causes of the various pathological con- 
ditions connected with the teeth at the most diverse 
periods of life are many which are related to that 
period which immediately precedes and accompanies 
the processes attending the second dentition. The 
process of development and eruption of the second 
teeth is a perfectly normal one, but, like many other 
of the natural processes of the organism, it is fre- 
quently subject to deviation from the normal course 
of events by which many unexpected and startling 
results are often induced. It is well known that the 
first teeth are developed from the primary dental 
germs, which at the time of the formation of the 
deciduous teeth give off a series of diverticula, the 
germs of the permanent teeth. At the time of the 
development of the second teeth, the alveolar ridges 
are occupied by the bodies of the primary or decidu- 
ous teeth, their roots extending more or less deeply 
into the substance of the bone. The permanent teeth 
assume the form they are ultimately to possess by 
means of growth toward the external surface, the 
108 



PATHOLOGICAL CONDITIONS. 109 

tooth being pushed, as it were, from behind toward 
the mucous membrane by the continuous growth of 
the radical extremity from the tooth germ at first, 
and, later, from the peridental structures. For a 
short distance there is no unusual impediment to the 
growth of the tooth in its way to the surface, but 
soon it must inevitably be opposed in this direction 
by the body or root of the tooth already formed, 
which occupies the place toward which it is advanc- 
ing. Now and here commences one of the most 
interesting as well as one of the most inexplicable 
processes of the whole life of the individual. As the 
crown of the permanent tooth advances toward the 
surface of the alveolus, the tooth which is in front of 
it undergoes a process of gradual absorption, com- 
mencing at the extremity of the root and progressing 
slowly toward the crown. The loss of substance by 
the deciduous tooth is not accompanied by the symp- 
toms of caries, for there is no disease of the body of 
the organ. The individual suffers no pain, nor is 
there any evidence of inflammatory action about the 
shaft or the root of the tooth. The body of the tooth 
simply disappears from the apex of the root toward 
the free end, until there may remain only that por- 
tion of the organ which is above the gum, to which 
it is attached only by the ring of mucous membrane 
clinging to the sides of the tooth. If such a tooth 
be extracted at this time, it may be found with only 
a fraction of its natural root, or the root may be 
entirely absorbed and the body of the tooth be abso- 
lutely wanting below the level of the alveolar surface. 
It is not definitely known how this remarkable 

10 



110 DENTAL PATHOLOGY. 

change takes place, nor how or by what means it is 
accomplished. These are questions yet unanswered, 
and may well be classed among the difficult prob- 
lems of our science. The published descriptions 
of this process are still variously unreasonable and 
illogical, and some careful student might well make 
this part of dental histology the subject of special 
studies. Some of our best text-books assert that there 
is a new formation of bone in the neighborhood of 
the absorbing tissues, which new bone is itself imme- 
diately absorbed in its turn. This is so unusual a 
course in any of the processes of the human body, in 
the fulfillment of the natural phenomena of develop- 
ment, that it may well be doubted if it is ever 
strictly true; or, should it really exist, it may be 
looked upon as pathological in its nature. Much 
has been said concerning the so-called "absorbent 
organ of the primary teeth." It is described as con- 
sisting of round cells much like those of granulation 
tissue.* The tissue is probably made up of granu- 
lation tissue and of nothing else, and it may occur 
here in one or both of two forms : First, as the mate- 
rial out of which the new structures are being formed, 
as is the case in the early embryonic tissues, a rem- 
nant of which is preserved as the germ of the per- 
manent tooth, as already described; or, second, as 
the result of the normal irritation preceding and 
accompanying the second dentition. This is a fact 
which, so far as I know, has been universally over- 



* See an interesting contribution upon this point by Prof. Frank 
Abbott, New York. 



PATHOLOGICAL CONDITIONS. Ill 

looked, and the views here presented would seem to 
perfectly account for the phenomena so frequently 
described in long and perplexing detail by other and 
vague methods. Many of the symptoms commonly 
connected with the processes of the second dentition 
are those occasioned by any serious disturbance of 
the general system, and may be produced by many 
other causes than by the eruption of the teeth. 
The peculiar irritation attending the development 
and eruption of the second dentition has, doubtless, 
a causative effect in the production of this condition 
at this time; but it is quite secondary in character, 
and would be induced equally by any other serious 
change which might be going on in the youthful 
body. Should the idea here expressed appear improb- 
able, or be considered unlikely to exist in a natural 
process, the question may very properly be asked : 
Why not some disturbance in the processes of den- 
tition, as well as in those of pregnancy, which is 
equally a natural process? We are indebted to the 
careful studies of Tomes for much valuable informa- 
tion upon the origin and development of both the 
deciduous and the permanent teeth ; but, like other 
investigators, Tomes has not always reached proper 
conclusions in his researches, and these require correc- 
tion at the hands of his successors. These mistakes 
are most frequent in relation- to the histology of the 
structures which he mentions, from his descriptions of 
which one can derive no clear idea of his meaning, 
or arrive at an accurate conception of the processes 
described. His methods of study seem to have been 
careful, but his conclusions are often erroneous. 



112 DENTAL PATHOLOGY. 

The advent of the permanent teeth makes neces- 
sary a greater alveolar space than was necessary for 
the first teeth. The individual teeth are larger, 
longer and stronger than the deciduous teeth, thus 
requiring an increased arch for their accommodation, 
as well as a greater amount of hone for their proper 
fixation in their places. The additional teeth in each 
jaw also make necessary a greater amount of space 
for their growth. The question of the enlargement 
of the jawbone to provide for the greater number of 
teeth in it would seem to be easily determined by 
prima facie evidence; but, in reality, there has been 
much discussion upon the matter as to whether the 
jaw really naturally enlarges, whether the form of 
the arch is changed, whether the growth of the bone 
is peripheral, interstitial, or both, and, finally, Avhether 
the bone is larger in any way or not. There can be 
no question that the bone is materially increased in 
size and in weight, and that this increase is both 
peripheral and interstitial; but it is manifestly im- 
possible to define by a mathematical equation the 
relative and absolute changes in the various parts of 
a bony structure having the complicated form and 
function of the alveolar arches. The various attempts 
which have been made to obtain accurate informa- 
tion upon this subject by means of operations on the 
bone are, in most cases, misleading, as they ignore 
almost completely the changes due to inflammation 
in and about the bone, which follows the operation, 
and may result in necrosis of the surrounding hard 
structures, or in some other accident of this kind, and 
thus obscure and nullify the experiment. There 



PATHOLOGICAL CONDITIONS. 113 

should be a series of experiments on many animals 
under the most favorable conditions, and especially 
under the strictest aseptic and antiseptic precautions, 
and the mean result of all these experiments would 
give the best indication of the direction and amount 
of growth of the bone. The process of intermittent 
injections of coloring matter into the blood might be 
tried with advantage, and the course of recovery after 
fracture of the bone would be full of interest in the 
study of the direction of its growth. One experi- 
ment, or one series of experiments, can possess only 
a trifling worth in the study of physiological or 
pathological processes. A truthful result can only 
be obtained by long and patient studies by various 
methods and in many cases, and even then there is 
always a large margin for errors and various con- 
tingencies. 



114 DENTAL PATHOLOGY. 



CHAPTER XIV. 

ANOMALIES. FORMATIVE DEFECTS. DEFICIENCY OF 
TEETH. 

Among the various abnormal conditions noticed 
in relation to the teeth, one of the most striking is 
that in respect to their number; that is, to the de- 
fective development of the germinative forms out of 
which the primary teeth are later constructed. It is 
believed by many observers that the earlier races of 
human beings possessed a normal denture consisting 
of a considerably greater number of teeth than is at 
present found in the mouth, and that this enlarged 
original number of teeth has become diminished 
through the occurrence of changes in the surround- 
ings of the human family, and through variations in 
the habits of living, and in the degree of civilization. 
Consequently, the present denture of the human 
species is considered, by a large number of natural- 
ists, as the degenerated form of an originally larger 
denture. It is a fact that, among the variations of 
number in the development of the teeth, the devia- 
tion in the direction of excess of the normal denture 
is frequently observed. The increase in number of 
the teeth is looked upon by the believers in the 
" descent of man " as a partial reversion toward the 
earlier natural denture of the human race, and so 
far, as not distinctly pathological. The individual 
teeth so produced in excess of the usual number are 



ABNORMALITIES OF THE TEETH. 115 

denominated " supernumerary teeth," and are prob- 
ably more frequently situated in the incisive region 
than elsewhere in the jaw, and are also more fre- 
quently developed in the upper than in the lower 
jaw. The more common deviation from the normal 
denture is, however, in the direction of a diminished 
rather than an increased number of teeth, so that the 
tendency would seem to be toward a further reduc- 
tion of the number of the dental organs, beyond that 
which has already occurred since the original den- 
ture of primeval man. 

The causes operating to produce a congenital 
variation of the number of the teeth must be sought 
during that period in the existence of the individual 
at which the different tissues and organs are being 
developed, that is, during the intra-uterine or the 
embryonic period. The actual cause of these devia- 
tions is still surrounded with obscurity, but it would 
seem that some disturbance in the distribution of the 
germinal matter out of which the organs and tissues 
of the growing embryo are constructed, must be the 
original source of the disarrangement of the dental 
structures in most cases. If this should prove to be 
the correct theory, we may safely consider that the 
disturbance must occur, or at least commence, at a 
period somewhere in the earliest weeks of intra- 
uterine existence. At present the whole subject of 
the origin of congenital malformations is clouded by 
superstition and veiled in ignorance. In some cases it 
may be possible to ascribe the malformation to some 
known cause, as the defective constitutional condition 
of the parental organism, or some other potent cause 



116 DENTAL PATHOLOGY. 

operating upon the maternal system at the period 
when the malformation of the embryonic structures 
is supposed to have occurred. The existence of cer- 
tain diseases in the body of the mother, and notably 
the presence of Syphilis, is a frequent factor in the 
faulty construction of the foetal organism. The effect 
of this malady upon the forming tissues of the 
embryo is to render them more frail and friable, and 
to diminish their power of resistance to any inju- 
rious influence, so that the organs and structures of 
an individual affected with this disease in its con- 
genital form are more liable to take on morbid action 
than those of a healthy individual. It is quite prob- 
able that certain other constitutional affections are 
transmitted directly to the tissues of the offspring, 
without producing sufficient immediate change in 
the organs to attract attention. 

In studying cases of supposed deficiency of the 
teeth it is necessary to observe the greatest caution 
in order to avoid mistake. The number and the 
individual character of the remaining teeth should 
be first ascertained, and a searching investigation 
must always be made in order to ascertain if there 
exist any mark by which the loss by extraction or 
decay of one or more missing teeth may be detected. 
Very frequently the patient cannot give a satisfac- 
toty account of the number of teeth originally pos- 
sessed, or state if any have been lost. The existence 
of a depression in the alveolar process, indicating the 
absorption of the bone, is often a valuable hint from 
which the early extraction or loss of a tooth may be 
determined. The statements of the patient may be 



ABNORMALITIES OF THE TEETH. 117 

innocently or willfully misleading. This is particu- 
larly liable to occur when any considerable number 
of teeth are represented, or believed to be congeni tally 
absent. The absence of any of the teeth belonging 
to the normal denture is not a frequent occurrence, 
and the congenital absence of a larger number is par- 
ticularly rare, and should be carefully investigated. 
A case is reported in one of the German journals in 
which there is represented a total deficiency of the 
permanent teeth, but there is some doubt as to the 
accuracy of the facts in the case. I do not know of 
any other case deserving credence. Cases of partial 
congenital deficiency of the teeth are more frequently 
reported, and many exist which are never reported, 
from the fact that their bearers are not aware that 
any abnormal formation of the oral organs exists; 
the patient experiences no discomfort, and knows no 
different condition. A case in illustration of the 
lesser defects of congenital character is known to the 
author, in which the primary dentition was normal 
in every respect, and ran its usual course, excepting 
that the lower central incisors were not shed until 
the fifteenth year. In the upper as well as in the 
lower jaw, how T ever, there appeared only one pair of 
incisors in the second dentition, and curiously 
enough, there were in the upper jaw two strong and 
massive central incisors, but no laterals, w r hile in the 
lower jaw there were no permanent central incisors, 
but there were two normally formed and shapely 
lateral incisors. There were never any centrals in 
this jaw. The upper incisors (centrals) were very 
large and there was a congenital cavity in each. 



118 DENTAL PATHOLOGY. 

The teeth suffered no perceptible change for some 
years, but have recentty been carefully filled with 
gold as a precautionary measure against their further 
decay. Since that time their condition has not 
altered. In any other part of the jaw than the in- 
cisive region, a congenital deficiency of the teeth is 
usually accompanied by a shortening and narrowing 
of the alveolar process, or of the whole jaw. This is 
the more noticeable when the deficiency occurs in 
the denture of the lower jaw. The distortion of the 
jaw is more marked when the molar region is the 
seat of the defect, as the alveolar process is there 
more massive. It would seem as if the alveolar pro- 
cess were arranged to accommodate only the number 
of teeth actually present, and not those which should 
normally be present, but which in these cases have 
not been developed. The deformities of the jaw 
accompanying deficiencies of the teeth may be very 
strongly marked, and are usually found to accord 
with the alveolar arrangement of those teeth which 
have been developed. Thus, we sometimes find that 
the alveolar process is greatly shortened on one or 
the other side, or the jaw may even be transposed 
bodily to one side, so that the interval between the 
two central incisors is no longer in the median line 
of the face, but is displaced to one side. Sometimes, 
though rarely, the deficiency is so great that only a 
few teeth are present in the jaw. Cases are recorded 
in which from two to four teeth composed all which 
had been developed in the jaw at adult life, and, 
curiously enough, these strongly marked deviations 
are often observed in the upper and lower jaw of the 
same individual. 



ABNORMALITIES OF THE TEETH. 119 

Another fact which at first seems very striking is 
that the primary dentition is often perfectly normal 
in those cases in which the secondary teeth are more 
or less deficient in number. This is probably due 
to the fact that in the foetal development of the in- 
dividual there was a normal definition of the tooth 
germs for the primary dentition, but the secondary 
tooth germs were only partially developed. The 
secondary tooth can only be produced when the 
germ for its development has been deposited from 
the germ of the primary tooth. The deformity of 
the denture is often hereditary, being transmitted 
from one generation to another, and is sometimes 
observed in the successive children of a family much 
in the same way as the hereditary variation in the 
number of the fingers and toes is transmitted to 
successive generations. Some instances are on 
record in which a deformity of the parents is not 
reproduced in the same form in the children, but 
takes some other shape or appearance, oftentimes 
presenting an anomaly before unknown in the family 
history, although due to a common cause with the 
other varieties. One such case is as follows : The 
father of the family long ago suffered from some 
obscure trouble which was not recognized at the 
time, and was not made the subject of treatment. 
The history of this malady is somewhat uncertain, 
but from the description given by those who have 
observed it, it was similar to that of the course of 
Syphilis. 

This man was the father of six children, of whom 
one was affected with epilepsy and died after reach- 
ing adult age, being for years a burden upon his 



120 DENTAL PATHOLOGY. 

family, and during the last part of his life being 
almost an imbecile. Another, the second, has cleft 
palate, and had a very pronounced hare-lip. The 
third has obscure and grave nervous symptoms. 
Thus three out of six children present evidence of 
defective formative force, but each in a different 
form ; and the patients do not themselves observe 
any connection, or trace any relation between these 
three members of this family. Another instance is 
that of a family in which the grandfather is sup- 
posed to have become infected with Syphilis, and to 
have transmitted this taint to his children. Of these, 
several were affected with Chorea, one was deformed 
and misshapen, and another lost all the permanent 
teeth upon the upper jaw at a period of life in which 
these organs are generally found in their best condi- 
tion. Of the third generation in this strange family, 
three of the offspring are blind ; while in the fourth 
generation, of which the members are still compara- 
tively young, there is not yet the appearance of any 
outspoken deficiency, but the children are sickly and 
weak. In eases in which an original organic defect 
exists in a parent, it is nearly alwa} r s propagated, 
and may often be detected in the offspring, although 
the particular manifestation of the defect may have 
taken a different form in the child from that which 
it presented in the parent. Defects of the mouth 
and teeth are among the most frequent lesions of 
this nature, and should, therefore, always be carefully 
studied, and the history of the case and the ante- 
cedents of the patient should be thoroughly investi- 
gated. 



SIZE AND LOCATION OF TEETH. 121 



CHAPTER XV. 

VARIATIONS IN SIZE AND LOCATION OF THE TEETH. 

The size of the teeth is, as a general thing, tolerably 
uniform, being about the same for corresponding 
teeth in the majority of people, of whatever condi- 
tion in life ; later, there comes a time at which Ihey 
naturally commence to exhibit the evidences of 
wear, and of the disintegration which is the result 
of long use, often hastened no doubt by carelessness 
and neglect. They at this time become gradually 
flattened by attrition, and frequently show the signs 
of atrophy of the pulp, or other serious changes due 
to disordered or suspended nutrition, or to the acci- 
dents and diseases to which the hard structures are 
liable in advanced life. 

The denture is, however, subject to large variation 
in the size of individual or of associated teeth, and 
at times presents deformities of these organs which 
must be classed as monstrosities, and resemble the 
malformations occasionally observed in other parts 
of the body, by which the natural contour and the 
normal function of organs or of entire parts may be 
seriously compromised, or entirely obliterated. 

The most frequent anomaly of form and size t>f 
the teeth is observed in individuals who from any 
reason possess teeth of a more delicate structure and 
smaller pattern than the majority. These organs 
may be perfectly healthy in structure, and may be 



122 



DENTAL PATHOLOGY. 



as durable as the teeth of most persons' so-called 
" sound " teeth : being in no way remarkable except 
from their diminutive size. In some cases the decid- 
uous teeth may not be notably small, but the dental 
arch may be unusually large, and the teeth may be 
separated from each other by an unusual space, 
which gives to the organs collectively the appear- 
ance of being diminutive in size, because they do 
not fill the enlarged arch to the usual degree, and 
present spaces between the neighboring teeth. The 
enlarged spaces between the primary teeth are 
oftener observed in the incisive region than any- 
where else, as here the alveolus is oftener abnormally 
lengthened than in any other part of its course. 
The teeth, too, in this region are more frequently of 
diminutive size. Sometimes it becomes necessary 
from cosmetic reasons to insert an artificial tooth to 
fill the space thus formed, and the artificial tooth is 
almost always placed between the central incisors, 
thus showing that it is in the intermaxillary region 
that most of these anomalies occur. The primary 
incisive teeth are often elongated and pointed like 
the canines; in cases of irregular development of the 
denture, it may therefore be difficult to determine' 
the character of an individual tooth in this region. 
The body of the tooth so deformed is usually narrow 
and rounded in its contour, so that the entire tooth 
is really smaller than normal. The tooth or teeth 
thus affected may be perfectly healthy in structure 
and may possess a good degree of durability, being 
in no way remarkable excepting from their diminu- 
tive size. The milk teeth are in other cases so large 



SIZE AND LOCATION OF TEETH. 



123 



and strong that they are mistaken for permanent 
teeth, and they remain an unusually long time in 
the jaw, and are occasionally mistaken for a part 
of the permanent denture. In this case the teeth 
are much larger in proportion than is the dental 
ridge in which they are contained, and they are 
often situated at an angle in the jaw, or may overlap 




It has a conical crown, is well covered with enamel, and somewhat worn away 
transversely at the extremity. The incisors upon the right side slightly 
overlap, while those upon the left side stand within the dental range. The 
right segment of the dental arch extends about three millimetres more 
posteriorly than the left, on account of the insertion of the supernumerary 
tooth. 



each other, and thus cause great distortion within the 
mouth ; and at the same time they lay the foundation 
for a similar irregularity of arrangement in the teeth 
of the permanent denture. The primary set being 
too large to be properly accommodated in the space 
designed for these teeth, are obliged to assume any 



124 DENTAL PATHOLOGY. 

position which will allow them to come to maturity, 
and thus are sometimes found far out of their proper 
line, and even protruding in a lateral direction from 
the jaw. The direction of the tooth must in these 
cases have been materially changed by the unusual 
crowding of the dental arch, and with the change 
in its location and direction there is associated a 
change in the position of its root. With this must 
be usually combined a malposition of the germ of 
the permanent tooth which is to follow it in the 
second denture. 

The permanent tooth, which is in the meantime 
being developed in the tissues surrounding the root 
of the deciduous tooth and is already slowly approach- 
ing the surface of the gum, as the root of the primary 
tooth is absorbed to make room for its advance, thus 
takes an abnormal direction, and, finally, erupts from 
the mucous membrane in a direction and at a loca- 
tion far from the normal. This condition seldom 
affects one tooth alone ; and occasionally the entire 
denture is affected and produces the distortion of the 
teeth, of which we see some notable examples in daily 
dispensary practice. At times the direction of the 
teeth may be varied from some accidental cause, 
when the teeth are not of unusual size and the 
alveolar arch is sufficiently capacious. The deform- 
ity may then be removed by careful treatment, in 
restoring the teeth to their normal position by means 
of gentle and prolonged traction in the desired direc- 
tion, so that they will occupy their proper position, 
when the line of the dental arch will be perfectly 
restored and the normal contour of the jaw estab- 



SIZE AND LOCATION OF TEETH. 125 

lished. It sometimes occurs that the teeth become 
so crowded and distorted by the large size of the 
individual organs, or by a diminution of the size of 
the arch, that one or more of their number may be 
mechanically forced into a position nearly or quite 
horizontal to their normal direction and to the alve- 
olar process, thus lying at a right angle to the line of 
their proper growth. This condition does not fre- 
quently present itself, and when it really occurs it 
is often mistaken for some other malformation. It 




A wedgedshaped narrow upper jaw of a young person, in which both lateral 
incisors have emerged upon the lingual side of the dental range, in conse- 
quence, perhaps, of some interruption in the development of the jaw, or, it 
may be, from the protracted retention of the lateral milk incisors. The 
rhiht milk canine tooth has fallen out. (From a plaster east.) Two-thirds 
natural size. 

is more frequently observed in the upper jaw, and 
oftener affects the molar teeth than any others. The 
wisdom teeth are more frequently the seat of this 
deformity than all the other teeth together. This 
seems to be due partially to the fact that all the 
other teeth are already matured at the time when 
the wisdom teeth are erupted, and perhaps, also, 
because there is on one side of the wisdom teeth a 
firm wall composed of the teeth already grown and 
11 



126 DENTAL PATHOLOGY. 

in position, while upon the other is only the loose, 
cancellated structure of the posterior portion of the 
alveolar process, which has become softened and 
changed by the process of preparation for the wisdom 
tooth as it is about to protrude from it. If from any 
cause a slight change should occur in the direction 
of the growing wisdom tooth at this time, it might 
easily deviate from its normal line of growth to such 
an extent as to place its plane of advance entirely 
within the alveolar process, the tooth burrowing for 
itself a cavity in any direction which it may chance 
to take. Sometimes this is in an inward direction, 
win n the crown may pierce the inner border of the 
alveolar-palatine region and appear as a prominence 
in the roof of the mouth. 

The tooth may turn backward and outward and 
lead to the formation of a sinus, opening in the 
mucous membrane upon the labial surface of the 
gum. This was well illustrated in a case seen by 
the author not long since, in which a foul discharge 
had existed in the mouth for a long time. The 
patient was led to seek relief from the insufferable 
odor of the mouth as well as from the sickening 
taste and the persistent nausea which had lately been 
present. The discharge was traced to a small open- 
ing on the outer side of the gum, which was the 
orifice of a moderately large sinus, which had resisted 
repeated attempts for its obliteration at the hands of 
several experienced surgeons. At the time I saw the 
case, the opening was of the size of a pin's head, and 
passed obliquely into the soft tissues, upward and 
backward toward the spheno-maxillary fossa. At a 
depth of about two cm. a mass of hard tissue was 



SIZE AND LOCATION OF TEETH. 127 

detected by the flexible steel probe, which was mov- 
able, though attached, not sensitive, and upon pres- 
sure over this point a large amount of putrid pus 
was expelled. By careful enlargement of the existing 
opening a view of the cavity and its contents was 
obtained, and the probe could now be passed entirely 
around a large body, which might be an encapsulated 
sequestrum, or it might be a misplaced tooth con- 
tained in a suppurating cavity. All opinions united 
upon the latter method of explanation, and a forceps 




A twisting of both central upper incisors, occasioned, probably, by a hyperostosis 
in the palatal suture. The labial surfaces of both permanent central 
incisors are turned laterally, the lingual toward the median line; the lateral 
milk incisors are twisled laterally at an angle of nearly J5°; the milk molars 
are in their normal positions; the first permanent tooth has emerged. The 
maxillary arch is narrow. Natural size. (From a plaster cast, for the use 
of which the author is indebted to Prof. Strasky.) 

was at once carefully applied, and a perfect tooth 
was grasped and at once removed from the deeper 
part of the cavity. 

It occasionally happens that the tooth, particularly 
an incisor, is turned upon its axis, so that the edge 
instead of the broad surface is presented toward the 
lip, and the other edge is presented to the oral cavity. 
The tooth then is found with its surfaces transverse 
to the direction of the alveolar process. 



128 



DENTAL PATHOLOGY. 



CHAPTER XVI. 

FUSION OF ADJACENT TEETH. 

In certain cases there may be a fusion of adjacent 
teeth, in which they are so united as to present either 
the appearance of a simple junction of neighboring 






Actual size. 

SECOND PERMANENT MOLAR WITH FUSION OF ROOT TO BODY OF WISDOM TOOTH. 
WISDOM TOOTH IS CLUBBED AND EXTREMELY IRREGULAR IN FORMATION. 





SECOND PERMANENT MOLAR FUSED 
WITH WISDOM TOOTH, WHICH IS IN- 
VERTED. BODY OF WISDOM TOOTH 
IS CLUBBED, ROOTS ARE NOT DE- 
VELOPED. 



organs, or they may be joined in such a manner as 
to constitute a deformed and misshapen mass, con- 
forming in no way to the usual shape or appear- 
ance of any normal tooth. This rare condition may 



FUSION OF ADJACENT TEETH. 129 

affect any of the teeth, and I have specimens showing 
the existence of fusion in different parts of the den- 
ture ; but it is probably more frequently observed in 
connection with the wisdom teeth, which seem to 
present a marked tendency to abnormal formation 
of all kinds, and present the most frequent examples 
of partial or complete fusion. 

At times the diagnosis of this condition becomes a 
matter of more than usual difficulty, owing to the 
seat and location of the fusion. It may affect the 
molar teeth, and the point of fusion may be situated 
near the root, so that there may be no external sign 
of the union of the adjacent organs; while in some 
cases the presence of a diseased condition of the soft 
tissues over and around the part may call attention 
to the possibility of fusion of the adjacent teeth as a 
cause. The existence of a long-standing and refrac- 
tory discharge from the mucous membrane near to, 
or removed from the margin of the tooth, with the 
added feature that it is not amenable to the ordinary 
methods of treatment for this condition, should call 
attention to the radical fusion of the tooth which is 
visible, with some part of a deformed or misplaced 
organ which may be wholly contained beneath the 
surface of the mucous membrane, and can only be 
detected by careful examination, and possibly only 
after incision of the soft tissues. At times the tooth 
is contained within a chamber of bone, and it is 
necessary to excavate a passage in order to reach it, 
when it may be grasped with forceps and loosened, 
and then be removed in conjunction with the second 
tooth with which it is united. Two such cases are 



130 DENTAL PATHOLOGY. 

known to me, and form a part of the morbid speci- 
mens collected for the purposes of instruction in the 
Boston Dental College. When fusion occurs in the 
incisive region, the teeth are more frequently united 
by their lateral borders ; and less frequently present 
serious deviations of shape in the way of actual 
deformity, than in any other part of the denture. 
When the incisors are thus united, there is generally 
a longitudinal groove running from the edge of the 
massive fused tooth to the gingival border, at the line 
where fusion of the original separate organs occurred. 
The fusion may be confined simply to the exposed 
portion of the teeth, or it may extend to the extremity 
of the root, and thus form a complete union of the 
organs. In teeth in which the union is partial, the 
pulp canal is generally developed as a separate 
chamber in each portion of the double tooth, but in 
cases in which the fusion is complete to the apex of 
the root, there is usually one large and distorted pulp 
chamber, which serves for the entire double organ. 
Sometimes the crown is variously distorted, having 
an irregular number of cusps, arranged in the great- 
est confusion, or being traversed by chasms in the 
enamel, which run in various directions, showing an 
irregular or an intermittent growth of this organ. 
The teeth then often decay early, from the exposure 
of the dentine, which is easily attacked by carious 
disease, or from some inflammatory affection of the 
pulp or periosteum, induced by the exposed situation 
and imperfect condition of the crown, which thus 
leads to the extraction of such teeth, and so to the 
knowledge of the monstrosity which they constitute. 



FUSION OF ADJACENT TEETH. 131 

The patient frequently becomes aware of the exist- 
ence of any peculiarity in the mouth only when his 
attention has been called to the condition of the 
oral organs by the dentist to whom he repairs for 
advice. 

Another cause of malposition or deviation in the 
arrangement of the teeth is found in the existence 
of abnormal bony or cartilaginous growths in or near 
the alveolar process, such as exostosis, or hyperostosis, 
or some of the forms of enchondroma, or from the 
occurrence of inflammatory changes in the structure 
of the bone. The presence of the so-called cancer- 
ous growths in the soft parts about the teeth may 
also cause alveolar deformity by inducing absorption 
and softening of the bone, which allows the teeth to 
be easily pressed out of place and turned in any ab- 
normal direction. The character of these growths 
will generally have been recognized before such ex- 
tensive changes in the tissues and in the location of 
the oral organs has occurred. The malposition of 
the teeth in a case of the disease just mentioned 
would be a secondary process, and would depend 
upon the preexistence of the malignant disease be- 
fore mentioned. Treatment in such a case would 
not be directed to the distortion of the teeth, but to 
the eradication of the malignant and destructive 
disease wdiich caused it, and would necessarily con- 
sist in the removal, if possible, of the entire mass of 
diseased tissue, with any teeth or other parts which 
might have become involved in the destructive pro- 
cess. The pathological growths of the gingival and 
labial region are of very diverse character, and pro- 



132 DENTAL PATHOLOGY. 

duce varying results according to their seat, and the 
effect of the different forms of disease upon the parts 
in which they are situated. Many entirely different 
and distinct diseases of these regions have been 
grouped together by careless observers under the 
head of Epulis, and this faulty classification has 
done much to originate and perpetuate the confusion 
which has long existed in regard to the pathology 
of the various tumors of the oral cavity, and its 
immediate vicinity. 

The term Epulis is a misnomer, as there is no form 
of disease which can properly be designated by this 
name. There are proper and characteristic appel- 
lations for all the pathological growths found in the 
neighborhood of the teeth and jaws. The diseases 
and other disturbed conditions of this region do not 
essentially differ from the same forms of disease in 
other parts of the body, and it is an error to add to 
the already large nomenclature of pathological con- 
ditions, by the introduction of special names for use- 
less distinctions. 



RACHITIS. 



CHAPTER XVII. 

EACHITIS. 



A certain disease of the general system called 
Rachitis often produces great distortion and de- 
formity in the hard structures of the body ; and at 
times affects the jaws, occasioning more or less irregu- 
larity in the arrangement of the teeth. The seat of 
this lesion is in the bony structures, and is due to a 
mal-assimilation of the elements of the food taken ; or 
to an actual deficiency of certain of the substances 
which are necessary in the system for the proper con- 
struction and preservation of these structures. In 
the condition which is induced by this disease, the 
bones are found in a softened state, the osseous skele- 
ton is rarefied ; the cancellous portion is diminished, 
the cells enlarged and the structures are very elastic, 
so that they yield to pressure, without fracture of the 
bone. The condition of the bone in cases of rachitic 
deformity is variable. The amount of animal mat- 
ter in the osseous structures is much augmented and 
the earthy matters correspondingly diminished. The 
actual comparative weight of the fresh and of the 
dried bone would no doubt yield interesting results, 
but to my knowledge this has not yet been applied 
to the jaw. The rachitic bone can often be readily 
cut with a knife, and upon attempting to break it, a 
degree of flexibility is noticed which allows it to 
bend freely, but it will not break readily. The effect 

12 



134 DENTAL PATHOLOCxY. 

of the abnormal composition of the bony structures 
is more frequently observed in other parts of the body 
than in the jaws, where comparatively little pressure 
is directly brought to bear on the parts from exter- 
nal sources. A greater degree of deformity is observed 
in rachitis of the lower extremity, in which the bones 
are subject to greater distorting force ; and they are 
often found to be bowed outward by the weight of 
the trunk in walking, at a time when the bone is too 
soft and flexible to support the strain. The joints at 
the knee and the ankle are often dislocated to a 
greater or less degree, and a deformity is thus pro- 
duced which is not recovered from during a lifetime. 
Chemical analysis proves that the bones of a rachitic 
person contain less lime than those of healthy indi- 
viduals. As this element is the principal one by 
which the strength of the bone and its resistance to 
injuries is secured, it is of the highest importance 
that it should be present in a sufficient amount to 
insure these ends. The diminution of the lime-salts 
in the bones would simply make them weak and 
brittle. The rachitic bone is flexible and elastic. 
This effect is the opposite to what we should expect, 
and it is produced by another deviation in the struc- 
tural integrity of the bony tissues, which is a highly 
increased amount of the cartilaginous elements of 
the bone. At an early period of existence the greater 
part of all the bony structures is a mass of cartilage. 
The bones are " cast," as it were, in this soft, elastic 
material. A knife would easily cut them in any 
direction. Bone-tissue cells or blood-vessels are not 
found in any part, nor is the structure of bone to be 



RACHITIS. 135 

observed. All parts of the skeleton so far as it can 
be discerned at that time are composed of this uni- 
form soft, pliant material. Very soon, however, a 
change in the histological elements is observable. 
Bone cells begin to present themselves in the bor- 
ders, or at certain definite points in the cartilage, and 
soon a small spot may be perceived which is already 
hard, and opposes the knife. By chemical agencies 
the presence of lime may now be determined. The 
microscope shows the existence of the organic ar- 
rangement of true bony tissue. The bone cells are 
observed arranged in relation to the Haversian 
canals and sending off minute canaliculi into the 
calcareous mass by which they are surrounded. 
Blood-vessels are now observable, and the soft, gela- 
tinous, vascular tissue of medullary substance becomes 
noticeable. A dense, firm layer of periosteum is 
found surrounding the bony formation, and sending 
prolongations into its interior, and the bone is thus 
rendered complete in all its physiological elements. 
In rachitic bone, this change of tissue has never 
been fully completed. The bones have indeed taken 
to their structure a large portion of lime, but they 
have never been fully ossified, and still contain a 
large amount of chondrine in their composition, by 
which they are rendered flexible at a time when 
they should be firm and unyielding. The weight of 
the body now becomes sufficient to bend the legs out 
of their proper line, and thus is produced the condi- 
tion called " bowlegs." Other parts of the body may 
also become misshapen from this cause, as the back, 
and in women frequently the pelvis, and in some 



136 DENTAL PATHOLOGY. 

cases other bones, among which the jaws are to be 
included, though a deformity of rachitic character 
in the jaws is among the rarer forms of this patho- 
logical condition. 

The effect of this condition when present is two- 
fold. It allows distortion in the arrangement of the 
primary denture, in which the teeth may be found 
at an angle to each other, and often twisted upon 
their axes, and otherwise displaced, and it also ma- 
terially changes the relations of the germs of the 
second dentition, which arc still within the alveolar 
process. The second dentition approaches its devel- 
opment at the proper period, but with the germs of 
the growing teeth so changed in direction that they 
often protrude in a very irregular manner. Some- 
times the arrangement of the teeth may be so pro- 
foundly disturbed in their germ sockets that the 
tooth does not advance toward the free surface at all, 
but is entirely retained within the bony tissues, in a 
cavity which it forces for itself in the alveolus. In 
the various manifestations of the disease of which we 
have been speaking, we may always notice one pe- 
culiar fact, which is that the teeth themselves are 
never in the slightest degree altered in their struc- 
tural elements or in their physiological development 
as individual organs by the presence of rachitis. The 
teeth in any rachitic condition of the bony structures 
at large are always found perfectly developed, as 
would be the case if rachitis did not exist. Thus, 
while one hard structure is profoundly affected and 
its functional integrity seriously interfered with, an- 
other neighboring hard structure is not at all affected 
by the same disease. 



INFLAMMATORY AFFECTIONS. 137 



CHAPTER XVIII. 

INFLAMMATORY AFFECTIONS. 

Of all forms and varieties of pain to which the 
human subject is exposed, the distress occasioned by 
an inflammation seated in the pulp of the tooth and 
extending to the periosteum of the root, is probably 
one of the most agonizing. It is said that even the 
stolid and hardy Indian will shriek and moan like 
the veriest child under the agony of an inflammation 
of the tooth -pulp with its excruciating exacerbations. 
The pain from a tooth is said to be the only form of 
physical torture which will completely deprive the 
Indian of that firmness which renders him at once 
the admiration and the terror of all civilized people. 
It is the only excuse which he will himself think of 
offering or will receive from another for disability, 
without the taunt of cowardice. 

There is not another structure in the human body 
in which the sensitive tissues are distributed in a 
manner so liable to cause distress upon the slightest 
insult or injury, and in which the slightest disease is 
accompanied by so astonishing an amount of pain as 
in the tooth. All through its vascular portion there 
is found an abundant distribution of sensitive nerve 
fibres accompanying ever} 7 connective-tissue filament, 
and like it being only barely accommodated in its 
dentinal sheath. The slightest diminution in size 
of the dentinal canal, or the least infringement in its 



138 DENTAL PATHOLOGY. 

calibre by pressure from without, must compress the 
delicate nerve filaments lying within it ; and the 
least pressure upon a sensitive nerve filament means 
pain. An enlargement of the bulb of the nerve fila- 
ment itself, from swelling or inflammation, would 
produce a similar effect, intensified by the presence 
of a diseased condition in its substance. When we 
think of a structure like that of the pulp of a tooth, 
consisting to so large an extent of nerve substance, 
and endowed with such exquisite functional integ- 
rity, we cannot wonder at the intensity of the pain 
which accompanies inflammatory conditions of these 
organs. The only surprising thing is, that in the 
constant state of use and of abuse of these organs, the 
instances of organic or functional disturbance of the 
dental structures are not more frequently noticed. 
The degree of immunity from directly injurious in- 
fluences to which the teeth are continually subjected, 
is so great that scarcely one per cent, of cases of 
inflammation in these organs is due to any other 
cause than structural changes in the textures of the 
dental tissues, or to sudden mechanical insults in- 
flicted upon them, or occurring in their immediate 
neighborhood. The causes which produce the 
remaining very large majority of cases may be any 
of the numerous lesions affecting the teeth ; but by 
far the greater number are due to carious or necrotic 
conditions in or around the teeth themselves. In 
the greater number of cases the pulp cavity of the 
tooth has been opened by a carious perforation, and 
the delicate nerves contained therein have been ex- 
posed to irritation from foreign and external sub- 



INFLAMMATORY AFFECTIONS. 139 

stances. Cases of simple inflammation, so-called "idio- 
pathic " cases, are so rare that some good observers 
doubt their existence; and certainly a very accurate 
diagnosis must be formed, when caries is to be abso- 
lutely excluded. The irregular formation of some 
healthy teeth often simulates commencing caries, 
and is a constant source of distrust and concern to 
the careful dental surgeon ; and this uncertainty is 
vastly increased when we are told that the same tooth 
is the seat of excruciating neuralgia. The similarity 
of symptoms in many cases of caries to those of com- 
mencing peridental disease is another constant source 
of uncertainty, as the pathology and treatment of 
these two conditions is in no wise the same. 

In many cases, the only accurate method of form- 
ing a correct diagnosis is to observe the course of the 
disease. The behavior of the organs for a short time 
would do much toward deciding in favor of a pure 
necrosis, or an inflammation with its structural 
changes of tissue. The presence of inflammation is 
determined by the existence and sequence of certain 
phenomena, and the behavior of the tooth toward 
influences which usually produce no particular 
effects. The pain is often confined at first to one par- 
ticular portion of the tooth, such as to one cusp of a 
molar, and the rest of the tooth is not only free from 
pain, but is not even sensitive to pressure upon it. 
The pain often increases in severity, and becomes dis- 
seminated, like other forms of neuralgic distress, until 
not only the whole of the diseased tooth, but also the 
neighboring teeth, become the seat of as great an 
amount of pain as the tooth first affected. At times 



140 DENTAL PATHOLOGY. 

the sensory nerves distributed to the corresponding 
side of the face and head and neck are also affected, 
and the patient is at times unable to say where the 
pain is most intense. If we examine the tooth we shall 
generally discover the existence of caries in some 
part, which has penetrated, or has at least approached, 
the pulp cavity of the tooth. The pulp is exquis- 
itely sensitive to any external impression. Particles 
of food, the atmosphere, cold, fluids, and various other 
substances, are sufficient to produce great pain, though 
at that time pressure upon any other part of the 
tooth may not be the occasion of any distress. For 
a time the pain seems to be of a purely neuralgic 
character, and to be unaccompanied by any positive 
inflammation of the dental textures, and while in 
this condition it is sometimes possible to remove the 
cause of irritation, by filling the cavity which usu- 
ally exists, or by other appropriate measures, and the 
pain i.s thereby perfectly and permanently cured. 
The age of the individual has much to do with the 
character of the teeth, and with the personal suscep- 
tibility to pain. The existence of pregnancy is also 
accompanied, with a certain degree of frequency, by 
pain in the dental region, as well as in other parts 
of the body, and the termination of gestation is no 
less frequently the signal for complete relief from 
much distress in the teeth. The relief is often com- 
plete and unbroken, until the occurrence of the next 
pregnancy, when, after a period of a few weeks or 
months, there may be a return of all the distressing 
symptoms we have before seen developed in the pa- 
tient, which endure, as at the earlier period, until the 



INFLAMMATORY AFFECTIONS. 141 

patient is delivered, when they again suddenly cease. 
At times this series of phenomena is repeated through 
successive pregnancies, extending through many 
years. The teeth sometimes remain a remarkably 
long time in the same general condition, and under 
ordinary circumstances occasion the patient no un- 
easiness, but in the change which is produced in all 
the functions by the existence of pregnancy, they 
seem to become hypersesthetic, and then often cause 
most acute suffering, until the ordinary condition of 
the system is once more restored. At times in the 
history of advancing caries, there may be a longer or 
shorter period in which slight causes will provoke 
excruciating pain, when the dentine has been re- 
duced to a very thin layer which transmits to the 
pulp every sensitive impression of temperature or 
pressure, and often awakens most acute distress. This 
seems to be a simple traumatic neuralgia, and to de- 
pend upon external irritation, and not upon any 
degree of inflammation of the tooth pulp. The acces- 
sions of pain occur suddenly, and without premoni- 
tion, subsiding gradually, and leaving the sufferer 
free from pain for a time, when they may recur on 
some new irritation being applied to the tooth. There 
is no heat or other appreciable sign of inflammation 
about the tooth. The time arrives, however, when 
the thin shell of dentine still remaining over the 
sensitive pulp is penetrated by the carious process. 
The tooth has gradually become more and more sen- 
sitive to changes of temperature, and to the presence 
of foreign bodies in its vicinity. The patient becomes 
more and more cautious in mastication and in taking 



142 DENTAL PATHOLOGY. 

hot or cold substances into the mouth. At length 
mastication is no longer performed on that side of 
the jaw, on account of the pain caused by small par- 
ticles of food in the cavity of the tooth. The patient 
is often obliged to avoid lying upon the affected side 
of the face when asleep, and is forced to exercise 
every care to avoid pain. At length a sudden acute 
pain occurs in the pulp, which often brings tears into 
the eyes of the strongest person, from its great 
severity, and at once renders the patient incapable of 
any effort other than to seek ease from the terrible 
agony. The advent of distress is usually occasioned 
by biting upon something, but at times it is impos- 
sible to determine the particular cause. The pain 
often seems to extend to other teeth than the one 
primarily affected, and sometimes even includes the 
entire distribution of that part of the fifth nerve. 
After a longer or shorter period the acute pain gener- 
ally diminishes into a dull, extended ache, which 
subsides slowly, and at the end of some hours may 
have entirely ceased, so that the sufferer may for a 
short time be free from pain and may obtain some 
repose. The remission is generally of short duration, 
as the pulp is now exposed, and is liable to irritation 
from external influences of all kinds, when the same 
excruciating pain is sure to recur, to go through the 
same course of abatement and temporary relief as 
before. Another train of events takes place at this 
stage; the exposed pulp soon becomes inflamed, and 
this is accompanied by a different condition of the 
tooth and its surroundings than we have above con- 
sidered. 



INFLAMMATORY AFFECTIONS. 143 

The first appearance noticeable to an observer, is 
the redness of the pulp tissue, which generally is 
apparent at the point where the pulp is exposed, and 
is accompanied by a swollen and puffy condition of 
the soft parts, thus causing them to protrude from 
the orifice to a greater or less extent. At this period 
•the pain is generally of a more continuous and wear- 
ing character than in the earlier stages of the disease, 
owing to a permanent pressure upon the delicate 
nerve fibres, caused by the swelling of the soft tissues 
within the unyielding structures of the tooth. The 
pain and swelling may be circumscribed, affecting 
only a single papilla of a molar, or it may be a 
general inflammation of the whole tooth. The former 
is more frequently the case where the perforation is 
very small and situated at one extremity of a tooth 
otherwise sound. The other form is observed in teeth 
which are much decayed, or in which the perforation 
is large, especially in a frail and weakly person. The 
redness may be very intense, owing to marked hyper- 
emia of the soft tissue, and often it amounts to hem- 
orrhage into the pulp, as extravasation, such as may 
accompany other forms of acute inflammation. When 
there is an effusion of serum into the tissues, the 
color passes into a more or less intense yellow tinge, 
and soon assumes a greenish hue, due to commencing 
suppuration. Suppuration is the general consequence, 
or at least the common sequence of the inflammatory 
process, and is usually followed in the tooth by a 
cessation or, at all events, by a diminution of the 
pain, due to the disorganization of the tooth pulp by 
the inflammation, or to the atrophy of the nerve ele- 



144 DENTAL PATHOLOGY. 

ments themselves, by which the} r cease to be painful. 
The examination of the pus from the cavity of a tooth 
presents nothing unusual. It consists of elements 
similar to those found in pus from other suppura- 
tions, viz., pus cells (white corpuscles of the blood), 
serum, mucus from the saliva, and debris of the 
adjacent tissues, together with various foreign mate- 
rials which are introduced from without. These are 
most frequently found to be particles of cotton fibre, 
portions of food in different stages of disintegration, 
starch granules, bacterial forms, and a host of other 
variable substances which are either contained in the 
solids or liquids taken by the mouth or are inhaled 
or otherwise introduced from the outside. These are 
for the mosl part innocuous, as they are of small size 
and usually of soft structure; but some varieties are 
injurious from the results of chemical decomposition, 
which is easily induced in the mouth, and is accom- 
panied by the liberation of deleterious gaseous and 
other products, by which the breath is made very 
offensive, -and which must have an injurious effect 
upon the general health of the individual. The influ- 
ence of suppuration upon the pain is produced by 
the structural changes induced by this process in the 
nerve elements. These delicate structures gradually 
lose the clear, sharp outline which they ordinarily 
present under the microscope, and become cloudy, 
indistinct and granular. The cell elements undergo 
fatty degeneration, by which their functional integ- 
rity is destroyed, and soon they are seen to become 
broken up into irregular masses of a friable nature, 
which are cast off like any other necrosed tissue. 



INFLAMMATORY AFFECTIONS. 145 

The fatty degeneration and necrosis is prolonged into 
the fine canals of the dentine, and here is often 
accompanied by decomposition of the cell elements, 
with the evolution of a fetid odor and the feeling of 
malaise on the part of the patient, not to be con- 
founded with any other similar condition unless with 
that of commencing typhoid fever. The dentine and 
enamel are often discolored from the action of the 
decomposing matter, so that the teeth become of a 
tan- or even deep-brown color, and lose their lustre, 
seeming more like the charred ends of bone than 
like the teeth. The pain often diminishes in a nota- 
ble manner in these advanced stages of the disease, 
so that the patient is in no suffering, and the teeth 
often do service long after they are deprived of sen- 
sation, these being the " dead teeth " so often spoken 
of by dentists. They cause little or no irritation to 
the tissues surrounding them, and, being deprived of 
their original vitality, are retained in place as inno- 
cent foreign bodies would be, and are frequently of 
great use in mastication. They sometimes wear away 
rapidly at the crown, and become much grooved and 
beveled by attrition, but otherwise are often free from 
destructive changes. Sometimes they become, to a 
greater or less extent, separated from the gums or 
mucous membrane, so that they are loosened, and 
allow foreign substances, like tartar, to penetrate 
toward the root of the tooth. This also allows the 
decomposition of the particles which lodge there in 
eating. The careful and regular use of a proper 
tooth brush is here indispensable, if the tooth is to be 
saved, as otherwise the process of suppuration may 



146 DENTAL PATHOLOGY. 

be set up, and may advance to such an extent as to 
allow the tooth to fall out by the merest accident, or 
even in chewing. 

The food should be selected with reference to the 
condition of the teeth, and all hard substances should 
be sedulously avoided. In some cases the injurious 
effects of certain articles of food may be observed by 
means of their destructive chemical action upon the 
teeth. By this cause the teeth are sometimes so 
eroded and excavated that they scarcely protrude 
above the gums, but appear as brownish elevations 
in the alveolar line. In this condition they may 
still exist for many years without further appreciable 
change, and may even render considerable service in 
mastication. 



GANGRENE OF THE PULP. 147 



CHAPTER XIX. 

GANGEENE OF THE PULP. 

Another variety of disease of the pulp cavity is 
sometimes observed, in which the soft tissues of the 
interior of the tooth become gangrenous, and awaken 
a new train of symptoms, due to the dangerous char- 
acter of the changes accompanying this condition. 
This affection occurs more frequently in children 
after the more acute form of inflammation of the 
pulp, following caries, especially of the deciduous 
teeth. It is also occasionally observed as a conse- 
quence of diseased conditions of the periosteum or 
other peridental structures. In certain cases no cause 
can be assigned for its appearance, although it would 
seem that some irritation must have been present, 
as it is difficult to understand how the gangrenous 
condition could have arisen as an idiopathic affec- 
tion. From whatever source it may have originated, 
the result is the same. It almost invariably causes 
the destruction of the pulp contents, either through 
a process of mummification by which all the moist- 
ure is abstracted from the tissues, and the pulp is 
left as a shriveled and dried mass of much less vol- 
ume than it formerly possessed, lying in the original 
pulp cavity; or, as is more frequently the case, the 
whole mass breaks down rapidly into a uniform 
cheesy, greasy, smeary substance, containing the ele- 
ments of the tooth pulp, which have been reduced 



148 DENTAL PATHOLOGY. 

by sudden decomposition, associated with fatty de- 
generation, to this condition. 

The general character of the case is similar to that of 
gangrene of any other soft, moist tissue of the body, 
and is at times observed in wounds, or more frequently 
in certain cases of pulmonary disease. The decom- 
position of the fatty products sometimes occurs, with 
the formation of the fatty acids which may be dis- 
covered in the mass, by means of the microscope, as 
long, needle-shaped crystals, either single or collected 
into clumps of varying size. These can be tested by 
proper reagents in the same manner as other chemi- 
cal substances. The caustic alkalies are capable of 
forming a solution with fatty substances, when united 
with them by the aid of heat. They become saponi- 
fied, and are then soluble in water. Bacteria are 
also generally found in cases of gangrene after acute 
inflammation. These organisms are intimately asso- 
ciated with the process of putrefaction in animal 
tissues, and seem to be a necessary factor in the 
production of this change. They possess different 
degrees of importance or else the body is variously 
susceptible to them, for they are at times vastly more 
abundant, and much more potent in their influence 
upon the system than at others. These bodies are in- 
troduced into the organism from without, and are not 
originally produced within the system under any cir- 
cumstances. They swarm in all putrefying wounds 
and are found in thousands in the liquid which 
escapes from such wounds. They increase in num- 
ber with astonishing rapidity, by a proliferation from 
the parent organism. They are seen to move about 



GANGRENE OF THE PULP. 149 

in the liquid in which they are found, but this 
quality is thought to depend upon molecular activity, 
rather than upon any power of direct locomotion in 
the organisms. The nature of the bacteria has 
long been a matter of dispute between pathologists, 
but it is now considered as definitely settled that 
they belong to the lowest ranks of the vegetable or- 
ganisms, and they are included among the crypto- 
gams or schizomycetes. These low forms of organic 
life are transmitted by means of germs contained in 
the atmosphere, or by the use of implements or in- 
struments which are contaminated by bacterial 
forms in some stage of their existence. The great 
mortality which attended all general surgery in 
hospital practice in the years gone by, was due in 
great measure to the infection of open wounds by 
bacteria, or by their germs; and the history of almost 
every hospital institution presents appalling records 
of mortality from the most trivial injuries and the 
slightest operations. One of the greatest triumphs 
of the present century has been the development and 
successful -introduction of the Lister system of anti- 
septic surgery, by means of which a wound is placed 
under conditions which render it impossible for any 
septic material to gain entrance from the outside 
air, and recovery is usually then rapid and complete, 
and is free from the dangerous complications so often 
met in earlier times. Indeed, many operations 
which were formerly considered as especially dan- 
gerous, are now attempted with full confidence in a 
successful result. 
33 



150 DENTAL PATHOLOGY. 



CHAPTER XX. 

CHRONIC INFLAMMATION OF THE TOOTH AND ALVEO- 
LAR PROCESS. 

Besides the acute inflammatory diseases connected 
with the tooth pulp, which we have above consid- 
ered, there is another form of this process, a slow, 
persistent, chronic form of the same condition, 
which is developed slowly, progresses very moder- 
ately, and lasts indefinitely. There are in these 
cases usually none of the violent symptoms which 
make themselves so painfully manifest in the acute 
forms of the disease. The disease may occur as a 
consequence of caries, or in the history of some other 
affection of the tooth. There is first a swelling of 
the soft tissues, as the result of the caries, which 
nearly always attends this form of the disease, but 
the swelling is not so marked as in the acute forms, 
and is productive of comparatively little pain ; or 
may occasionally cause no distress whatever. There 
is generally a circumscribed area of suppuration, 
but the discharge is of a sanious character, and not 
abundant. The odor is often offensive, from the de- 
composition of the elements of the dental tissues, the 
reaction of the decayed masses is generally acid, and 
the chemical action of this upon the dentine is to 
soften it by means of decalcification, and so to allow 
it to break down easily. The various external in- 
fluences to which the teeth are exposed, such as ex- 



ALVEOLAR INFLAMMATION. 151 

tremes of heat and cold, etc., produce pain. When 
the discharge continues for a long time there is often 
noticed a wearing away of the tooth about the spot, 
where it looks as if it were eroded or chemically 
disintegrated. This is generally due to the action 
of the purulent fluid to which the dentine is con- 
tinuously exposed, and which acts as a solvent to it 
and produces a gradual absorption of the calcareous 
elements, thus depriving that portion of the tooth of 
the firmness and resistance necessary to the perform- 
ance of its function. The softened dentine is held 
in place by the cohesion of its particles, and by the 
protection of the neighboring parts, and acts as a 
focus for the further destruction of dentinal tissues. 
The other forms of inflammation which are confined 
to the tooth alone are very rarely met with, but may 
properly be mentioned at this place. The forms of 
idiopathic abscess sometimes observed, in which 
there is a collection of inflammatory products in the 
substance of the tooth itself, without any symptoms 
of caries or other affection, are very striking illustra- 
tions of this. The most of the cases now on record 
are from the lower animals, especially the elephant 
and the horse. In them these imperfections are 
much more common, on account partially, doubtless, 
of the larger size of the teeth, as well as from the 
fact that they are also much more noticeable than 
these organs are in many smaller animals. 

The elephant, too, presents another structure, the 
tusk, in which evidences of obscure inflammations 
are at times observable, in the shape of deposits of 
various character. In certain instances the mark 



152 DENTAL PATHOLOGY. 

of a previous injury are also present, and explain 
the diseased condition. Fractures which have healed 
in an irregular manner are one of the frequent 
causes of this condition, as also are penetrating 
wounds of the enamel structure, when such wounds 
have not been followed by acute inflammation ; be- 
sides which probably the same result may be produced 
by many other causative affections of various kinds. 
An instance of this character came within the per- 
sonal knowledge of the writer, only a short time 
since. The tusk from an elephant presented within 
the shaft of ivory a mass of bony tissue, of spherical 
form, inclosing as in a capsule, a large bullet. There 
were no evidences of atrophy of the tusk, or of any 
interference with its growth or functions, but it 
seemed as if nature bad incased the foreign substance 
in an envelope of dense bono, and had there retained 
it in a harmless condition. A careful examination 
of the tusk showed no connection between the bony 
capsule around the bullet and the maxillary bone, 
and the question how to explain the presence of an 
island of bone in an ivory structure seemed a diffi- 
cult one to answer. A probable solution of the re- 
markable condition is that the animal received the 
bullet long ago, and not in the tusk, but in the max- 
illary bone at a point within the matrix of the tusk. 
The wound closed, after a certain amount of irrita- 
tion, and probably also suppurative inflammation. 
The irritation of the bullet stimulated the maxillary 
bone to a proliferation of bone tissue about the irri- 
tating body, the bullet was incased within a bony 
sheath, by which it was isolated, and thus rendered 



ALVEOLAR INFLAMMATION. 153 

harmless. The same principle may be observed within 
a beehive, where any offending substance is inclosed 
within a wall of wax, and thus hermetically sealed. 
The tusk continued growing, and carried the foreign 
body mechanically with it. In the slow process of 
growth, as the bullet became further and further re- 
moved from the matrix of the tusk, the connection 
between the bony capsule and the bone of the matrix 
became more and more attenuated, until at length 
it was entirely obliterated. Nature rounded the 
corners, and the growth of the tusk transported the 
entire mass further and further from the matrix until, 
at a period many years afterward, the animal died ; 
and in preparing the ivory for manufacturing pur- 
poses, the iron bullet, surrounded by its compact 
bony capsule, was found far removed from the matrix 
of the tusk, within the substance of which the bullet 
had originally lain, and from which it had been 
transported a great distance by the natural processes 
of growth. The covering was perfect, the osseous 
tissue seemed denser than usual, and was everywhere 
closely applied to the bullet. There were no signs 
of an abscess or other inflammatory process in the 
vicinity of the spot, and it is not probable that the 
bullet would have ever afterward been the cause of 
any further trouble. 

It will be seen that the presence of a foreign body 
in the bony matrix of an elephant's tusk might lead 
to the deposition of new bone about the location of 
the injury, by which it might become firmly encased 
in this material, and that this deposit or hypertrophy 
of bone might be mechanically transported along the 



154 DENTAL PATHOLOGY. 

shaft by the growth of the tusk, and thus account in 
a reasonable manner for the presence of true bone 
tissue in the midst of the dentine, at a considerable 
distance from any other bony structure. The result 
of this accident might not be a source of permanent 
detriment either to the animal or to the organ 
affected. The original wound gradually heals, the 
matrix of the dentine becomes restored, and the tusk 
slowly protrudes from its sheath as if nothing unusual 
had occurred. 

The well-known " Handbook " of Prof. Wedl con- 
tains an account of similar conditions in the tusks 
of elephants, but most of these have passed through 
the process of suppurative inflammation, and present 
cavities of variable size, some as large as a small 
orange. These cavities are uniformly described as 
being inclosed by a capsule of various tissues, within 
which was usually found a layer of dried and shriv- 
eled substance of a black or yellowish color, which 
was probably once soft tissue thrown out by the 
inflamed structures, in which the suppurative process 
was at that time carried on. 

There is a lack of care in the reported observations 
in regard to the seat of the original lesion, and the 
probable time which had elapsed since the occur- 
rence of the injury. If the injury should occur in 
adult life, and in the shaft of the tusk, it is difficult 
to believe that bone tissue could be formed about it. 
We know of no way by which bone could be prolif- 
erated in the midst of tissues of another character, 
as the product of an irritative process in these tis- 
sues. In no inflammation of any of the soft tissues 



ALVEOLAR INFLAMMATION. 155 

Fig. 25. 




Segment from tbe tusk of an elephant, containing an iron ball which has pene- 
trated as far as the pulp cavity and has formed a bulging protuberance upon 
its wall which has given rise to several superficially smooth, warty, new 
formations with broad bases, partially visible at (n) in the oblique view of 
the preparation. In the immediate vicinity of the ball, the cavities of small 
abscesses and also osteo-dentine, are perceptible. Two-thirds natural size. 




A portion of a transverse section of the molar from an Elephas Indicus from 
Ceylon, containing the flattened segment of a leaden ball. (For the use of 
this specimen the author is iudebted to Prof. D. L. Schmarda ) If the three 
dental subsiances be traced out, it will be seen that the enamel (a, a), at a 
certain distance from the fragment of the bill, and also the dentine (6, b), 
have been displaced by a substance (e, c), which forms an investment of 
varying thickness around the fragment of the ball and, when traced further, 
is found to enter into immediate connection with the cement. Hence the 
new formation was developed by a proliferation into the enamel and 
dentine. Natural size. — Wedl. 



156 



DENTAL PATHOLOGY. 



of the body do we see the formation of new bone as 
an independent structure, nor do we consider it rea- 
sonable to expect any permanent new structure of a 
character different from that of the surroundings to 
be produced in any location. 




An osseous new formation from the wall of the cavity of an abscess in the tusk 
of an elephant. From the internal surface (a) of the cavity of the 
abscess as far as (c), where the normal dentine commences, the dentine is 
displaced by an abundantly vascularized osseous layer. The blood vessels 
are transversely divided, for the most part, aud are surrounded by a 
luminous ring. The opaque dotted portions (b) correspond with the localities 
where granular cloudiness is visible , aud. here and there, the remains of the 
ivory may still be recognized. The brighter spots contain, for the most part, 
bone-corpuscles which appear in the figure in the form of puncta; in many 
places, e. g.. near the middle portion (indicated by transverse lines), the 
bone-corpuscles are wanting, and in place of them is seen merely a diffused, 
granular mass. At the zone of transition into normal dentine (c), quite bright 
spots are perceptible on the right side, which are suggestive of clustered 
globular masses ; upon the left are the openings of transversely and obliquely 
divided blood vessels, which are surrounded by a luminous ring and are 
imbedded within the dentinal substance. Magnified five diameters. 



In inflammation of bone, however, we often find 
hypertrophy of the bone tissue, and a frequent 
example is met with in recent fractures, and in fact, 
in almost any injury to the bones. The most instruc- 
tive illustration that I know, however, is afforded by 



ALVEOLAR INFLAMMATION. 157 

the study of the process of necrosis in bone. The 
diseased condition consists of the death of a portion 
of the bone, perhaps only a small scale upon the sur- 
face, or it may be a section of the entire cylinder. 
This becomes at once a foreign body, and being de- 
prived of nourishment, speedily loses its vitality. It 
immediately enters upon a course of retrogressive 
changes, and becomes a source of irritation to the 
neighboring tissues. The periosteum is detached 
from the surface of the necrosed portion, the soft 
tissues about the same become swollen and inflamed ; 
and a line of demarcation is soon apparent, consist- 
ing of granulation tissue which has been thrown out 
around the dead bone. This forms a wall about the 
dead portion, which serves as a protection to the sys- 
tem, by preventing the absorption of any product of 
the necrosis, or of its subsequent processes, which 
might operate to the great detriment of the whole 
body. Gradually the connection of the necrosed 
portion with the healthy parts is dissolved by the 
process of demarkation at the line of the living part, 
and after a time the dead bone is found as a white 
necrosed mass lying loose and perfectly detached in 
a cavity of the healthy bone. The periosteum has 
for its function the production of bone, and when 
it is irritated or moderately inflamed the result of 
the increased vital activity in this tissue is an aug- 
mented size of the bone already existing in the part. 
The presence of a portion of dead bone in an un- 
wounded part has for its first effect the irritation and 
inflammation in a subacute form of the periosteum. 
The increased activity of this membrane is followed 



158 DENTAL PATHOLOGY. 

by an augmentation of its specific product, and as 
the membrane is expanded over the surface of the 
dead bone, the product of the membrane is found in 
the shape of new bone upon the outer surface of the 
necrosis. Thus it occurs in many cases where the 
treatment of necrosis has long been delayed, that 
the dead bone is entirely inclosed by a shell of the 
new, living bone which has been produced by the 
action of the periosteum, and this shell must be 
pierced before the dead bone within can be reached. 
The shaft of the bone is oftentimes much enlarged 
by the deposition of new bone around it, and the soft 
parts arc frequently the seat of extensive swelling or 
other disturbance. Not infrequently an acute suppu- 
ration attends the process, and after some time finds 
its way to the surface by means of a canal or sinus, 
which it form- for itself through the soft tissues At 
times there may be a tendency for the pus to flow 
along the surface of the healthy bone, thus lifting the 
periosteum up from the surface of the bone. This 
causes an extension of the original disease, and 
increases the amount of the necrosis, which is fol- 
lowed by a corresponding aggravation of all the 
subsequent phenomena connected with it. 



159 



CHAPTER XXI. 

CARIES. 

Among the various pathological processes affecting 
the tissues of the dental organs, the peculiar degen- 
eration of the tooth structure called "caries" deserves 
more than passing mention. This affection is one 
which acts upon the hard tissues of the tooth from 
without, and not from within, though some authori- 
ties maintain that the deterioration of the general 
health of the patient, which diminishes the vigor of 
all the organs of the body, may so reduce the vitality 
of the teeth that these structures become affected with 
decay from the suspension of the customary and 
necessary nutrition of the dental organs through the 
medium of the pulp and its connections.* 

Central Caries.! — " Many authors, Klencke 
among others, have asserted the existence of a caries 
which originates in the interior of the tooth, and 
in the cavity of the pulp. Nowadays most dentists 
pronounce against the existence of a central caries. 
It is true that the process of destruction often begins 
in a minute crevice or furrow in the surface, and 
so penetrates the dentine, even to the pulp-cavity, 
where it perforins its ravages, while the enamel of 
the surface seems intact, .at least to a superficial ex- 

* See exhaustive article ou "Dental Caries," in "American Sys- 
tem of Dentistry," Vol. I, page 729 et seq. 

t Leber & Rottenstein. Translated by Thos. H. Chandler, d.m.d. 



160 DENTAL PATHOLOGY. 

amination. This caries, though central, yet has its 
origin at the surface of the tooth. Therefore, in 
these latter days, the existence of a true central 
caries has been generally denied." 

Such a claim seems plausible in some of the cases 
of rapid decay of the teeth seen in certain persons, 
but it is more than probable that other and unnoticed 
pathological conditions contribute to the sudden loss 
of the teeth in these instances. 

Caries, in the ordinary acceptation of the term, is 
a degenerative process, which first appears upon some 
exposed and unprotected portion of the body of the 
tooth. 

" Since caries begins ordinarily at the crown of the 
teeth, the caries of the enamel constitutes the first 
stage of the process. The destruction reaches the 
dentine later, but the first pathological phenomena 
make their appearance in it, even before the enamel 
is destroyed in its whole thickness. Most frequently 
there is seen a black or brownish point in one of the 
furrows or folds of the crown. On examining a sec- 
tion of the diseased portion, the dark color is seen 
to have its seat in the superficial layers of the 
enamel, and penetrates clear to the bottom of the 
furrow, where the thickness of the enamel is, in 
general, less than at the other points." * 

It is of the nature of an advancing localized ne- 
crosis of the hard structures of the dental organs, 
which first appears as a spot of small size, and 
advances by extension to other portions of the tooth 

* Leber & Rottenstein. Translated by Thos. H. Chandler, D.M.D. 



CARIES. 161 

first invaded, and at length may attack the teeth 
adjacent to those primarily affected. The disease is 
of progressive character, and extends by continuity 
of tissue into new areas of the dental textures, which 
disappear before it, until the body of the tooth is 
extensively diseased and to a greater or less degree 
destroyed. As the disease approaches the cavity of 
the pulp canal, it awakens sensations of a dull pain, 
or a recurrent tenderness when pressure is exerted 
upon the tooth, which soon increases to a constant 
and agonizing distress, as the wall of the pulp canal 
becomes thinned by the advance of the carious pro- 
cess, until at length the pulp canal is opened, and 
the symptoms of an acute inflammation of this sen- 
sitive material are at once produced. This may be 
followed by suppuration within the cavity of the 
pulp canal, with the formation of an abscess at the 
root of the tooth, which may discharge through the 
pulp chamber and the perforation caused by the 
caries. Occasionally there is sudden and extensive 
necrosis of the soft tissues within the tooth, with the 
retention of the products of disintegration of tissue, 
which is sometimes followed by the signs of septic 
absorption and localized or general septicaemia. This 
is a serious condition under any circumstances, and 
is justly regarded by surgeons as a most dangerous 
complication. It is not frequent in affections of the 
teeth, but is occasionally observed, and has been the 
cause of death in cases of inflammation of the dental 
pulp. 

When inflammation of the dental pulp is followed 
by alveolar abscess, there is not infrequently an ex- 



162 DENTAL PATHOLOGY. 

tension of the destructive process to the wall of the 
alveolar cavity, with the necrosis of a portion of the 
bone situated at the apex of the root. There is then 
not infrequently a perforation of the body of the 
maxillary bone, with the formation of a swelling of 
more or less fluctuating character over the site of the 
disease. This sometimes goes on to the formation of 
a sinus to the surface of the skin, and the discharge 




A circumscribed necrosis upon the lingual wall of the left lower maxillary arch, 
coriesponding to the carious second molar: and also a finely porous osteo- 
phyte-fonuation upon the adjacent portion of the maxillary wall. The 
wisdom tooth (a) has just made its appearance. The discolored, necrosed 
portion is sharply defined, and adjacent to it is deposited a thin, finely-porous 
osteophyte, which spreads anteriorly upon the lingual surface as far as (6), 
and posteriorly nearly to the articular condyle. A fistulous opening was 
formed upon the facial wall of the jaw beneath the posterior root of the 
second molar. The porous osteophyte extends anteriorly upon this surface 
as far as the mental foramen and posteriorly to the condyloid process. 
Natural size. 

of purulent matter from it, with occasional portions 
of the necrosed and exfoliated bone which has been 
gradually loosened and extruded. The carious pro- 
cess may thus lead to other conditions, involving the 
tissues surrounding the teeth, and producing unex- 
pected complications, which are at times of serious 
character. 



CARIES. 163 

The cause of the decay of the hard structures of 
the teeth has long been the subject of study, and 
various theories have been advanced as to the way 
in which the tissues are affected by the carious pro- 
cess. It was thought that the disease bore a close 
analogy to the affection of the bones of the spine, 
the long bones of the extremities, etc., which com- 
monly goes under the name of caries of these osse- 
ous structures ; but a closer study of the two diseases 
shows that the processes affecting these different 
hard structures in no way resemble each other. 
Caries of the bones is an affection associated with 
either the previous occurrence of an injury, or it 
appears subsequent to a period of marked debility 
of the general health, or, third, it may be observed 
in patients who are the subject of scrofulous diathe- 
sis, of syphilis (hereditary), or are the victims of 
some other serious contamination, of inherited or 
acquired origin. The bones in these subjects are 
found to be softened, they present larger or smaller 
cavities in their substance, and they are frequently 
partially or entirely denuded of periosteum over 
those portions which are the seat of the carious pro- 
cess. When the vertebrae, or the bones forming the 
hip joint, are affected with caries, the bones are fre- 
quently much eroded, and often are more or less 
broken down, causing a great degree of disability, 
and producing marked deformity. 

Suppuration frequently occurs in the substance of 
the diseased bone or in its vicinity, and at times 
there is observed the formation of a well-defined ab- 
scess at the seat of the disease, which may perforate 



164 



DENTAL PATHOLOGY. 



the tissues and open upon the surface, or burrow its 
way along the track of the larger muscles, and form 
a fluctuating swelling in some adjacent part of the 
body. Caries of the bones may, under favorable 
conditions, end in complete recovery. There is not 
infrequently a permanent deformity of the part 
which was the seat of the caries, and there is often a 
bony anchylosis of the affected structures, so that 
subsequent disability of function supervenes ; but 




A segment of the left lower maxillary arch, in which is the cicatrix of a eircum- 
sii il.cil necrosis of the alveolar process, corresponding to the first and second 
molars. The mental foramen, somewhat more posteriorly than usual, is 
situated underneath the apex of the root of the second bicuspid (a). The 
facial wall of the three front teeth is removed. 



the carious condition may be entirely recovered 
from. Patients who have once recovered from 
caries of the bone seem to be free from any tendency 
to a return of the disease. 

In the occurrence of caries of the teeth, none of 
the peculiar features noticed in caries of the bones 
are observed. There is no tendency to suppuration, 
properly so called : there is seldom an extension of 



CAEIES. 165 

the disease to the alveolus or to the jaw, and there is 
usually no tendency toward recovery. The tooth 
which is attacked by the carious process is not likely 
to recover from the malady, but the disease is pro- 
gressive, and rapidly invades new portions of the 
dental structure, until the entire body of the tooth 
has been softened and destroyed, the pulp canal has 
been uncovered, followed by acute inflammation of 
the contents of the pulp-chamber, and the death of 
the tooth. It is a curious fact that caries of the 
teeth usually extends only to the level of the gum, 
and there stops, so that the roots and that part of the 
body of the tooth which is embraced by the sur- 
rounding tissues are retained for an indefinite period 
after the body and crown of the tooth have been en- 
tirely removed by the carious process. 



166 DENTAL PATHOLOGY. 



CHAPTER XXII. 

CAUSES OF CARIES. 



The cause of caries, its manner of origin, and the 
particular conditions which predispose to its occur- 
rence have long been questions of interest to the 
dentist. Many observations have been made to de- 
termine the nature of the process by which the most 
resistant tissues of the body are thus destroyed. A 
gradual consensus of opinion has been reached, in 
which nearly all observers now unite. The accepted 
theory of dental caries seems to be that the disease 
is one which always arises from external causes, 
and is due to external influences. The destruction 
always begins upon the exterior of the tooth. It is 
usually observed upon the surface of the enamel, 
and in most instances the point of origin of the 
disease is situated upon the surface of a cusp, or 
in a sulcus of the crown, or upon the surface of 
enamel which lies in proximity to an adjacent 
tooth. 

" The surface of the enamel is irregular, and pre- 
sents inequalities and depressions more or less devel- 
oped, and which may be few in number or scattered 
over the whole surface of the crown. These teeth 
are sometimes designated as " honeycombed teeth," 
from their resemblance to that article. In other 
cases we see the cutting edge of incisors notched or 
toothed, and sometimes of a conical shape, both of 



CAUSES OF CARIES. 167 

which forms are caused by deficiency of the enamel ; 
or the teeth contain parallel furrows crossing them 
horizontally. The name of erosion is given to these 
lesions, which show themselves at once upon several 
teeth, and yet they are but incomplete developments 
of the enamel, which have of erosion only the form. 
Finalty, the enamel is sometimes completely wanting 
upon a greater or less extent of the crown. The 
anomalies just described must be only too favorable 
to the establishment of caries, inasmuch as the agents 
of an injurious nature deposited in the cavities and 
irregularities of the teeth can extend their action 
without obstacle, and much better than on a polished 
surface. Fissures of the enamel occasioned by sud- 
den changes of the temperature may exercise the 
same influence. Doubts have been raised upon the 
possibility of seeing fissures of the enamel caused by 
changes of temperature, but these fissures are suf- 
ficiently frequent. In many cases the enamel of the 
greater number of the teeth, and sometimes, ev r en 
of all, is seen covered with chinks in every direction. 
They are most frequently caused by sudden changes 
of temperature, but sometimes are due to traumatic 
action. 

" No one at this day can refuse to believe in the 
necessity of the action of acids to occasion caries of 
the teeth. The salts contained in the enamel and in 
the dentine cannot be dissolved in water ; acids are 
indispensable to work their solution. But it is not 
at all necessary to employ strong acids for the pur- 
pose of separating the carbonic or even the phos- 



168 DENTAL PATHOLOGY. 

phoric acid from the lime with which they are 
combined. 

" Mr. A. Westcott and Mr. Dalrymple found that 
all the mineral, as well as vegetable acids, act 
promptly upon the teeth. Acetic and citric acids, 
for example, in forty-eight hours corroded the 
enamel to such a degree as to permit a great portion 
of it to be scratched away with the nail ; malic acid 
also produced very rapid effects. 

"The salts whose acids have a greater affinity 
for lime than for their own bases also acted upon 
the teeth. The acid tartrate of lime very rapidly 
destroyed the enamel. 

" Vegetable substances have no action until they 
ferment, and acetic acid is formed. Sugar, for 
example, which by itself has no action, produced 
its effects only in a state of acid fermentation. 

" Animal substances acted only very slowly, and 
only when they had reached a very advanced stage 
of putrefaction. 

" We have found that all substances capable of 
changing the dental tissues produce, at first, a 
deterioration of the enamel, which is soon followed 
by that of the dentine. The enamel, which in its 
normal state, is transparent, becomes quite opaque, 
milky, and in a more advanced state, chalky. 

" Our experiments are in harmony with those of 
Mr. Westcott and of Mr. Allport, and of Mantegazza, 
who found that all the vegetable acids without 
distinction attack the enamel of the teeth. 

" The different action of acids upon the different 



CAUSES OF CARIES. 169 

tissues of the teeth is explained by the presence of 
variable proportions of organic substances which 
enter into the composition of the enamel, the den- 
tine, and the cement. 

"After having established that acids of the most 
various kinds attack the teeth, it behooves us to 
inquire what are the acids which take part in the 
caries of the teeth, and how they get in the mouth. 
We know that acids are always introduced into the 
mouth with our food and drink. Acetic acid is 
associated with great numbers of viands as a condi- 
ment ; malic, citric and tartaric acids are found in 
different kinds of fruit, and in the drinks which are 
made from them ; oxalic acid is found in certain 
plants ; lactic acid in sour milk, etc. We have 
moreover pharmaceutic remedies which contain 
mineral acids and their acid ethers ; then tannin, 
some salts, alum for instance, are able to attack the 
teeth. All these substances may easily bring on 
caries or contribute to hasten its progress; but we 
think that the acid formed in the mouth as the 
result of decomposition, or those which are found in 
the buccal secretions, play in this manner a much 
more important part. As far as we know the veritable 
nature of the acids found in the mouth has not yet 
been demonstrated by any direct experiment, never- 
theless, it is generally thought to be lactic acid, and 
this opinion has greater probabilities in its favor."* 

The disease may at times appear upon the surface of 
the cementum, when this is exposed by recession of 

* Leber & Rottenstein. Translated by Thos. H. Chandler, d.m.d. 



170 DENTAL PATHOLOGY. 

the gum or other causes, but by far the most frequenl 
seat of origin of the carious process is the enamel 
surface of the crown of the tooth. The disease first 
appears as a spot of small size, and is usually ob- 
servable from a change of color ; the point of decay 
being usually of a brownish tint, which is easily 
perceived upon the pearly white of the surrounding 
surface. The textures of the tooth are found soft- 
ened, they have lost the normal consistence of ena- 
mel, and often it is observed that the disease has 
extended through the enamel, and has involved the 
dentine lying below it. The character of the change 
in the tissues of the teeth in the process of decay is 
believed to be a chemical decomposition of the cal- 
careous structures comprising the body of the' 
tooth.* This is thought to be due to the action of 
ncitls upon the alkaline textures of the body of the 
tooth, whereby new chemical substances are formed, 
which are in no wise similar to those of the normal 
tissues, and therefore are incapable of fulfilling the 
offices of these structures. 

Leber and Rottenstein state that "in our opinion 
the progress of caries of the enamel is this: By the 
action of an acid, the enamel becomes porous at 
some point, and loses its normal consistence. At 
the same time there is seen to appear a brown color, 
in consequence of the change which has taken place 
in its organic structure. There is formed at the 
surface a bed of leptothrix, which probably pene- 

*See also "Treatise on Dental Caries, "by Dr. E. Magitot. Trans- 
lated by Thos. Chandler, d.m.d., Dean of Harvard Dental School. 
Page 121 et seq. 



CAUSES OF CARIES. 171 

trates the dental cuticle, if it still exists, and destroys 
it. Chinks and fissures open in the enamel, which 
has become less consistent. Acid liquids and granu- 
lations of leptothrix penetrate there, while minute 
fragments become detached, and are promptly en- 
veloped by the elements of leptothrix, which, joined 
by the continued action of the acids, hasten the 
dissolution." 

The source of the acid substances which thus act 
to destroy the tooth is thought to be the decomposi- 
tion of saccharine matter or other materials which 
are capable of undergoing acid fermentation. The 
result of such fermentation is the formation of acetic, 
butyric, lactic or other organic acids, which from 
their known relation to alkaline bodies attack the 
tissues of the tooth substance, if they are allowed to 
remain for a sufficient length of time in contact with 
these organs. 

The result of this action is the formation of 
various chemical salts in the tooth substance, with 
softening of the material formed, and the progressive 
destruction of the substance of the tooth. The seat 
of commencing decay is also invaded by the germs 
of various organic bodies called bacteria, which are 
always found in situations where decomposition 
(putrefaction) is going on, and were at one time sup- 
posed to be the active factors in the production of 
the changes accompanying caries. This view has 
now been pretty generally abandoned, and these 
minute organisms are thought to be the universal 
accompaniments of the carious process, but are not 
believed to be its active cause. They are very 



172 



DENTAL PATHOLOGY. 



minute in size, and are found in other situations 
than the teeth, if putrefaction be present. They are 
thought to act to some degree the part of scavengers 
in the organism, and to produce further chemical 
changes in the decomposing mass in which they are 
contained, by which it is in some cases rendered less 




Softened, carious dentine, from a reinserted human tooth. Proliferations of 
leptothrix-matrix have taken place from irregular, pouch-like excavations 
into the dentine, along the course of the canals. Magnified 500 diameters. 



dangerous to the system. At all events, these germs 
are found in all cases of decay of the teeth, and may 
be observed by proper means of examination under 
the microscope. They are not detected in the tissues 
of healthy teeth, but are universally present in the 
contents of the excavations made by decay. 



CAUSES OF CARIES. 173 

Leber and Rottenstein have remarked " that the 
action of acids alone does not account for all the 
phenomena which appear in caries of the teeth. It 
is true that acids, even very much diluted, can attack 
the dental tissues, but we find, in their mode of 
action, differences which distinguish them from the 
phenomena, and from the progress of dental caries. 
The acids attack first the enamel and rapidly change 
it to a chalky mass ; later only, their action is felt in 
a marked manner upon the dentine, which becomes 
more transparent, and in fine, as if cartilaginous, by 
the very slow but progressive loss of its calcareous 
salts. Caries, on the contrary, proceeds slowly in the 
enamel ; it is much swifter in the dentine, where it 
proceeds promptly along the canaliculi. This differ- 
ence of progress must be attributed to the participa- 
tion of the fungi in the work of the caries. The 
elements of the fungus glide easily into the interior 
of the canaliculi, which they dilate, and thus favor 
the passage of the acids into deeper parts ; these 
same elements cannot penetrate a compact enamel, 
or at least they enter more slowly, and only when 
the elements which form it have been greatly 
changed by the action of acids. 

" But while, in ordinary circumstances, the fungi 
are found only at the surface of the buccal cavity, 
they are seen to jjenetrate into the interior of teeth 
during the progress of caries. For them to be able 
to penetrate thus it is necessary that the teeth be in 
a suitable condition; the enamel and the dentine 
must have lost their density by the action of acids. 

The opinion that caries is due to chemical changes 



174 DENTA.L PATHOLOGY. 

in the tooth substance, and not to the penetration of 
the tissues of the tooth by bacteria, is further 
strengthened by the fact that when the carious mat- 
ter is entirely removed, it is possible to preserve the 
tooth from further damage, by protecting the surface 
thus prepared from further chemical change by 
covering it with some material capable of prevent- 
ing further access of injurious materials to the dis- 
eased portion, and thus avoiding the chemical 
decomposition of the dental tissues. It would prob- 
ably be quite impossible to eradicate every organic 
germ from the minute canals of the dentine, even if 
this were desirable. We already know that the air 
we breathe, continually contains germs of many 
kinds, and that certain organic germs are found in 
the mouth in conditions of health, and it is quite 
probable that these bodies are not the elements of 
disease in cases of caries, but are associated with the 
processes of chemical decomposition, and particu- 
larly witli that of putrefaction. It is even thought 
that they absorb dangerous substances from the mat- 
ter around them, and by a process similar to that of 
digestion, transform these deleterious substances into 
other and harmless material. 

Caries of the teeth is most frequently observed in 
those persons who are not in the habit of carefully 
cleaning the teeth ; or in those in whom the diet is in 
some important respect either insufficient or of a 
quality not suited to the proper development of the 
dental structures. In such individuals there is usu- 
ally also a lack of care of the teeth, particles of food 
are allowed to remain in the interstices between the 



CAUSES OF CARIES. 175 

teeth or in the depressions between the cusps, and 
there soon undergoes fermentative changes, with the 
production of acid substances, which immediately 
attack the structures of the dental organs. The time 
required for the decomposition of organic substances 
in the mouth is not long, as the conditions under 
which fermentation would arise and be favored are 
continually present in the oral cavity. The interior 
of the mouth is constantly moist and warm, two 
conditions essential for the process of chemical de- 
composition of the class of substances which are 
taken as food. The presence of decomposing sub- 
stances in the mouth forms a favorite condition for 
the growth of bacterial organisms, which are inva- 
riably found as accompaniment of the carious process. 
The putrefying material derived from the destruc- 
tion of the dental tissues, added to that resulting from 
the decomposition of the articles of food which is 
always associated with the carious process, forms a 
mass of offensive matter in the mouth which is the 
cause of a peculiar odor, easily observed by those in 
the vicinity of the patient. 

The constant presence of decomposing matters in 
the mouth, and the continual inhalation of the putrid 
emanations from these substances with the breath, 
the fact that all the food which is swallowed is more 
or less contaminated from the admixture of foul and 
rotten substances, is a cause of deterioration of the 
general health and of a more rapid loss of the dental 
organs. AVith the loss of the power of mastication 
which the impaired condition of the teeth brings 



176 DENTAL PATHOLOGY. 

about, there is added another element of deterioration 
of the general condition of the system, which aug- 
ments the damage already produced by the disease 
in the mouth. The relations of caries of the teeth to 
the general health cannot be but seriously detrimen- 
tal in its character, and should lead the careful prac- 
titioner to advise early treatment for the restraint of 
the disease. The origin of the diseased process in 
chemical decomposition of organic substances in the 
mouth, and the disintegration of the tooth substance 
by the action of acids, affords valuable aid in de- 
termining the means to be employed for the preven- 
tion of carious degeneration, or for its cure if once it 
has appeared. No method of treatment will be of 
permanent benefit which does not have for its aim 
the eradication of all traces of the disease, and the 
protection of the carious surface from the injurious 
action of substances capable of prolonging the 
malady. The methods at present most approved by 
competent practitioners consist in excavation of the 
cavity formed by the carious process, its careful dis- 
infection by antiseptics, and the hermetical closure 
of the cavity by means of gold filling, or other appro- 
priate substances. So long as the cavit}^ thus treated is 
preserved in an aseptic condition, the process of decay 
is arrested. If, however, the surface of the diseased 
tissue be imperfectly covered, or if any portion of the 
disease be suffered to remain in the cavity, the de- 
struction of the tooth will be only temporarily 
checked, and will sooner or later again become 
active. 



CAUSES OF CARIES. 177 

In a few rare instances there seems to be an 
effort on the part of nature to stay the process of 
decay, and to preserve the tooth in a state of partial 
usefulness, even when the carious disease has become 
established. This may occur by the gradual forma- 
tion of a new layer of dentine, or other hard mate- 
rial, probably not always the same, which is devel- 
oped at the seat of the disease, and gradually extends 
over the situation of the carious degeneration, and 
forms an impervious protection to the true dental 
tissues beneath, so that they are not further affected 
by decay. This new deposition of tissue is usually 
seen in teeth which have become partially devital- 
ized, and are not the seat of living pulp. The way 
in which this process is carried out is not well under- 
stood, but the result of it is to furnish a new portion 
of hard tissue, which covers the diseased tissues in 
much the same way that a proper filling would do, 
and thus stays the progress of the caries. At times 
there is observed a deposit of such material in the 
pulp chamber of teeth which are not the seat of 
known disease, and in this situation they are some- 
times called " pulp stones." They are not known to 
possess any pathological importance, and are usually 
free from any indications of previous inflammation 
in the teeth in which they are found. At times 
there is an appearance similar to a mildly irritative 
process which is followed by a secondary deposit of 
dentinal tissue, and which may account for some of 
the pathological formations in the centre of the tooth ; 
but observations upon this point are not yet sufh- 



178 DENTAL PATHOLOGY. 

ciently numerous to warrant the statement of a 
positive opinion upon the subject.* 

* For an exhaustive and interesting treatise upon the nature of 
caries, and especially the relation which fungous organisms and the 
various fermentative processes hear to the destruction of the teeth 
by caries, see the admirable article on "Fermentation in the 
Human Mouth : Its Relation to Caries of the Teeth," by Prof. Dr. 
W. D. Miller, Berlin. Published in Independent Practitioner, 1884 
-85. and reprinted in "American System of Dentistry," Vol. I, 
page 791 et seq. " Dental Caries and Its Causes." Leber and 
Kottenstein. P. Blakiston, Son & Co., 1883. 



NEUROSES OF THE TEETH AND FACE. 179 



CHAPTER XXIII. 

NEUROSES OF THE TEETH AND FACE. 

A large class of affections of the head and face are 
grouped under the head of Neuroses of these regions. 
These disturbances are not always the same in appear- 
ance, they do not manifest themselves at all times by 
the same symptoms, they are not always similar in 
their pathological relations, and their behavior is 
not uniform under similar methods of treatment or 
surroundings. 

By the term " neurosis " is understood an affection 
which is sometimes confined to a restricted portion 
of the body, as to a certain limb or region of the 
body, or it may be distributed over a large area of 
the trunk or extremities, and include many different 
structures and organs in its domain. A peculiar 
feature of this condition is found in the fact that it 
is observed to follow the distribution of certain ner- 
vous trunks, and to be confined in its development, 
at least in its earlier stages, to the area of dissemina- 
tion of definite nerves of sensory or motor character. 

The seat of the disturbance which occasions the 
phenomena in any form of neurosis may be stated, in 
general terms, to be confined to one of three locations. 
It may be seated in the central nervous system, that 
is, in the substance of the brain or spinal cord ; or, 
second, it may be located in the nerve trunks leading 
to the various peripheral regions of the body, or their 



180 DENTAL PATHOLOGY. 

ganglia; or, third, it may be due to some affection 
of the distributory filaments or the nerve endings in 
the tissues to which they are distributed. These are 
not all of the same kind, as some of the nerves are 
directed to muscular tissue and cause the contraction 
of these fibres ; some are devoted to ordinary sensa- 
tion, and are the medium of our impressions of out- 
side objects from contact, while another variety of 
nerves is devoted to special sensation, such as those 
distributed to the organs of sight, taste, hearing, etc. 
Any or all these nervous structures may be the seat 
of neuroses of different kinds. 

The most frequent form of neurosis is that which ' 
finds expression in the form of pain, either local- 
ized in a limited area or disseminated over a con- 
siderable amount of the part affected. The general 
character of the pain is that of a lancinating or 
stinging sensation, which is sharply defined in its 
extent, and is not accompanied by any of the 
ordinary evidences of the processes of inflammation 
which usually cause the distress in cases in which 
there are inflammatory disturbances. There is 
usually no swelling, there is no marked elevation of 
the bod}' temperature, nor is there increased heat in 
the part which is the seat of the distress. There is 
no disturbance of the normal functions of the body, 
except in so far as these may be hindered b} r the 
existence of pain. The skin is usually not changed 
in appearance; even when the pain is most acute, 
there is generally no observable deviation from the 
normal appearances, either at the seat of the distress 
or in its vicinity. At times there is marked disturb- 



NEUROSES OF THE TEETH AND FACE. 181 

ance of function in the neighboring glandular struc- 
tures, which during the paroxysms of pain may be 
found in a state of exaggerated functional activity. 
Thus, in cases of neuralgic pain in the area of distri- 
bution of the first, or ophthalmic branch of the fifth 
pair of nerves, there is often an augmented secretion 
of the lachrymal fluid, and the tears flow over the 
patient's cheek on the affected side, even when there 
is no inclination on the part of the patient to weep. 
In cases in which the third branch of the fifth pair, 
the inferior maxillary nerve, is the seat of pain, there 
is often increased secretion of the salivary fluids, from 
reflex irritation of the nervous elements controlling 
the action of these glands. 

The pain in these cases is usually paroxysmal in 
character, frequently coming on without known cause, 
limited within sharply-defined boundaries, and fre- 
quently disappearing suddenly, leaving the part in 
a state of perfect health ; to return again after an 
uncertain interval and run the same course anew. 
The characteristics of all the neuroses, of which the 
picture here presented of a common neuralgia depicts 
but one, are its peculiar quality of occasioning the 
most acute suffering without exciting the appearances 
of inflammation in the parts which are the seat of 
distress. The distress is paroxysmal in character, 
and is usually interrupted by intervals of complete 
relief, in which no trace of the malady can be per- 
ceived ; nor can it usually be excited by ordinary 
causes. Added to this is the curious circumstance 
that when pain is excited in a certain limited part, 
the painful sensation is often transferred to other 
16 



182 DENTAL PATHOLOGY. 

parts and organs which are not the seat of any 
disease, but suffer from a distress which is due to 
reflex sensations arising from the primary neurosis 
in some other part of the body. An example of 
this is found in the frequent occurrence of agoniz- 
ing neuralgia in the various branches of distribu- 
tion of the fifth pair of nerves, which is observed 
during pregnancy, in which there is often absolutely 
no appreciable disease of the teeth or of their sur- 
roundings, but in which the pain is so intense 
that the patient's life is made a burden. Another 
form of the same condition is that in which there 
is persistent vomiting of reflex character, which 
at times so interferes with the nutrition that it be- 
comes a serious peril to the life of the mother. After 
exposure to certain injurious climatic influences, 
there is often noticed a peculiar susceptibility on the 
part of the patient to neuralgic or other neurotic 
affections, which occasion a great degree of distress 
to the patient, and often reach a point of extreme 
severity. 

There are a number of pathological conditions of 
the body which are accompanied by neuralgic pain 
as a constant symptom, which are not property reck- 
oned to the neuroses ; because the distress is in them 
caused by, and is secondary to, a distinct preceding 
condition of disease of the part, or of the nervous 
trunks leading to it, and is therefore ranked among 
some of the recognized forms of pathological deviation 
of the tissues or organs, and constitutes an organic 
disease in distinction to a Junctional disorder. The 
causes of this group of disturbances may be classed in 



NEUROSES OF THE TEETH AND FACE. 183 

a general way as belonging to the varieties of peri- 
neuritis, to the various forms of exostosis within the 
neural canals, or to the formation of tumors upon 
the trunks of the nerves or at their extremities, in 
all of which conditions there is usually an extreme 
degree of pain of neuralgic character. The first of 
these causes is probably by far the most frequent in 
the causation of the neuralgias clue to pathological 
growths. These cases are most frequently observed 
after trauma of some kind, and especially after frac- 
ture of bones, or following surgical operations affect- 
ing bony tissue in the vicinity of the neural canals. 
As the result of these disturbances, there is awakened 
an irritation in the wall of the bony canal, or at its 
orifice, by which new bone is produced, which, if it 
be deposited within the canal, must diminish its 
calibre, and thus compress the nerve or other struc- 
ture passing through the canal. The same thing 
is sometimes observed after infection with syphilis, 
and frequently follows the infective fevers — typhoid, 
diphtheria, etc. — though in these cases the cause is 
at times to be found in a thickening of the periosteal 
lining of the bony canal, which often subsides after 
recovery from the systemic disease. When the neu- 
ralgic distress is occasioned by disease, it is often 
possible to bring about a cure of the pain, by treat- 
ment of the general health, or of the condition of the 
body which has caused the disturbance, and which 
is frequently of an asthenic or debilitating character. 
This class of maladies is particularly frequent in 
those persons who have been exposed to the influ- 
ence of malarial conditions, or in whom the mala- 



184 DENTAL PATHOLOGY. 

rial cachexia is present, and constitutes one of the 
manifestations of this disorder. In these cases the 
remedies which are applicable to the treatment of 
the malarial complication, will often be sufficient to 
eradicate the neuralgia. 

In many instances, acute disturbance of the dental 
organs is occasioned by a neurosis originating in the 
ear and "affecting the parts to which the fibres of the 
fifth nerve are distributed, by what is called " reflex 
action," and this variety of the disease is distin- 
guished by the term " reflex neurosis." The irrita- 
tion which exists in one part is transmitted to the 
area of some other nervous distribution, and there 
awakens the symptoms of functional disease of those 
nervous trunks. At times the distress occasioned by 
a reflex neurosis is so acute that the most radical 
measures of treatment are eagerly sought by the 
patient, in order to obtain relief from the agonizing 
pain. In one case known to the writer, a severe 
neuralgia was developed in a case of fracture of the 
arm. The patient was a soldier, who had been much 
reduced in health by the hardships of army life, and 
by dissipation. The neurosis proved to be so refrac- 
tory that the patient at last was subjected to ampu- 
tation of the right arm above the elbow, in the hope 
of obtaining relief. This proved unavailing, and the 
arm was twice afterward reamputated, the last opera- 
tion being accompanied by the removal of the entire 
remaining portion of the arm at the shoulder joint ; but 
all was of no avail, and the patient is still suffering 
from a painful neurosis for which no further operative 
treatment is available, and which has obstinately 



NEUROSES OF THE TEETH AND FACE. 185 

resisted all known measures for the relief of neuralgic 
distress. In the jaw and teeth the existence of pain 
from reflex sources is sometimes so severe as to call 
for energetic measures for its relief, as it constitutes 
an agony so great that the patient cannot endure it. 
For this object, various operations upon the superior 
and inferior dental nerve have been suggested and 
performed. Among these are the removal of a portion 
of the body of the inferior maxillary bone at a point 
behind the wisdom tooth, near the angle of the jaw, 
by which the inferior dental canal is exposed, and 
the excision of a portion of the inferior maxillary 
nerve by means of scissors. This operation is some- 
times followed by entire relief from the distress, but 
unfortunately, in no small number of instances, the 
relief is only of temporary nature, and the original 
distress returns after a longer or shorter period in all 
its former intensity. 

Various neuroses of neuralgic character are due 
to disturbances of the nutrition, and seem to depend 
upon a deterioration of the standard of health in the 
individual, from causes affecting the general con- 
dition. These affections may betray themselves in 
many ways, but quite frequently are manifested 
by functional disturbances of sensation; and often 
there is pain in the area of the superficial nervous 
distribution, due apparently to the influence of 
external surroundings upon the trunk of the nerve, 
or upon its terminal fibres. Occasionally great 
local distress is caused in remote parts of the body 
by the presence and increase in size of a tumor, or 
some other pathological process in the brain, by 



186 DENTAL PATHOLOGY. 

which pressure is exerted upon the nerve trunks 
either at the point where they pass out through the 
skull, or upon some portion of their course within 
the cerebral structures. This constitutes a very se- 
rious condition, and there is little to be hoped from 
any form of medicinal treatment, except in those 
cases in which this manifestation may be due to 
syphilis, in which cases the administration of iodide 
of potassium in large doses may at times afford 
relief. In rare instances, when the seat of the trouble 
in the brain can be accurately located, the operation of 
trephining the skull might become a justifiable pro- 
cedure. 



PART V. 



CHAPTER XXIV. 

INFLAMMATION. 

By the term " inflammation " is meant the occur- 
rence of a series of phenomena which are associated 
with certain changes in the condition of the animal 
tissues, and which have, as the result of their action, 
a more or less extensive change in the temporary con- 
dition of the parts affected ; with the subsequent res- 
toration of the structures to their original condition ; 
or the result may be a permanent change in the con- 
dition of certain parts, or entire organs. 

The four principal phenomena associated with the 
existence of inflammation are the following: the 
Hyperemia ; the Exudation, with or without the for- 
mation of pus ; the Proliferation of Tissue, and the 
subsequent changes or degeneration of these new- 
formed tissues. 

These features are always present in any inflamma- 
tion of a serious character, though they may not be 
evident in an inflammatory process of small intensity, 
in which the whole process is of short duration. 
They are most plainly observed in such inflamma- 
tions as run a rapid and violent course, the so-called 
" acute " inflammations, and which terminate either 
187 



188 DENTAL PATHOLOGY. 

by the process of spontaneous subsidence, or by the 
subsequent occurrence of suppuration or of gangrene. 

The inflammatory action is induced as the effect 
of some irritant, or from some injury to the parts 
which are the seat of the inflammation ; or it may 
be due to some interference with the blood supply of 
the organ or part affected ; or with the nerves which 
ramify in the part. 

The first feature of an inflammation is the local 
Eypersemia of the part, This is produced by the 
increased amount of blood in the vessels of the part 
in which the inflammatory process is seated. Simple 
hypersemia in itself, however, does not constitute 
inflammation, but in inflammation there is always 
hypera3mia. 

The second feature of the inflammatory process 
is the Exudation into the part, and the occur- 
rence of Suppuration, if the inflammation should 
extend to this degree. The exudation is the most 
important of all the phenomena of inflammation. It 
may occur in three forms, according to its location 
in the body : it may exist as a free accumulation of 
inflammatory products in any of the cavities of the 
body; or it may be contained within the organs of a 
part, as the muscles, in the connective tissue, in the 
glandular structures, etc., or, finally, it may occur in 
the shape of an extensive infiltration into the tissues 
of the body, where it operates by pushing the natu- 
ral structures apart and filling a larger or smaller 
space in the part wdiich was previously occupied by 
these structures. 

The third feature of inflammation is the formation 



INFLAMMATION. 189 

of new tissues, or the hypertrophy, i. e:, the enlarge- 
ment or the thickening of the natural tissues of the 
part. One form of new growth in inflammatory 
processes is the adhesion of adjacent parts or organs 
to one another. This is seen particularly in the 
inflammation of the serous membranes, in which 
there is almost invariably a union of the surfaces 
one to the other, which is then a permanent condi- 
tion. The cavity of the serous membranes becomes 
obliterated, and the surfaces are grown together. 

The retrogression, or the removal of the exudation, 
is the fourth and last feature of the inflammatory 
process. This may take place in the way of gradual 
absorption of the exudative material, or it may take 
the form of the death of the tissue, as in gangrene, or 
in extensive abscesses in the tissues involved. 

The course of an inflammation is accompanied by 
four principal indications, by which the existence of 
the inflammatory process, and the degree of its in- 
tensity may be determined, and which may be re- 
garded as the cardinal symptoms of inflammation. 
They are the following : Pain ; Heat ; Redness, and 
Swelling, to which may appropriately be added a 
fifth, namely, suspension, or at least disturbance of 
function. The first four of these symptoms correspond 
to the old formula for inflammatory action, viz., 
Rubor, Calor, Tumor, Dolor, and are all present to a 
greater or less degree of intensity in any inflamma- 
tory process. At times the interference with the 
health and comfort of the patient may be so slight 
that the symptoms of a trivial inflammation may 
not become apparent to observation, or indeed be 



100 DENTAL PATHOLOGY. 

noticed by the patient, but careful examination of 
the part affected will always afford evidence of the 
existence of the conditions mentioned above. 

The invariable and universal origin of any in- 
flammatory process consists in some insult or injury 
by which the tissues were primarily affected ; or in 
the action of some irritant of mechanical or chemi- 
cal character ; or in some interference with the nor- 
mal and healthy nutrition of the part, as would be 
caused by any disturbance of the normal blood sup- 
ply ; or, lastly, with the distribution of the nervous 
influence in the portion of the body which is the 
seat of the inflammatory affection. Thus the cause 
of an inflammation of the surface of the body may 
have been the action of a high temperature, by 
which a burn has been produced, which is then the 
origin of an inflammatory process, which usually 
results in the healing of the part injured. Again, a 
part of the body may be subjected to pressure, by 
which its texture is crushed or bruised, and there 
we see the cause for inflammatory action in the injury 
resulting from the destruction of the normal consti- 
tution and relations of the tissues. Again, the freez- 
ing of the flesh by exposure to extreme cold may 
occasion a series of inflammatory changes, accom- 
panying the effort of nature to remove the dead and 
useless portion, the vitality of which was destroyed 
by freezing, from the adjacent part which was not 
affected to an extent sufficient to destroy its vitality. 

Any interference with the integrity of the parts or 
tissues of the body, or of any part of it, by opera- 
tions of a surgical nature, would also give rise to a 



INFLAMMATION. 191 

greater or less degree of inflammatory action. So 
that we must regard the cause of inflammation in 
any part or under any circumstances, as due to some 
disturbance of the ordinary and normal condition 
of the part, from unnatural and external, or at least 
abnormal causes or influences. 

The first visible symptom of inflammation con- 
sists in an increased redness of the part which is 
the seat of the injury, of whatever kind this may 
have been ; or in some cases the redness may be 
located not at the seat of the inflammation, but at a 
little distance from it. The latter condition is noticed 
in the commencement of an inflammation of the 
cornea, when the redness is not located upon the 
cornea itself, but is confined to the conjunctival 
mucous membrane ; from which it later may extend 
on to the cornea, until it reaches the seat of the 
original injury which caused the inflammation. 
A similar condition is observed in inflammatory 
conditions affecting cartilaginous structures, when 
the redness is located in the adjacent tissues, and 
not in the cartilage itself, which possesses no blood 
vessels, and cannot therefore show redness as a sign 
of inflammation, at the same time that this would 
be observed in the vascular tissues. 

The redness of the part which is the seat of a 
commencing inflammation is due to the fact that the 
vessels of the part which is the seat of the insult, and 
in which the inflammation is developing, are tempo- 
rarily paralyzed, and they therefore dilate, and allow 
a greater amount of blood to enter their channels than 
can take place in a natural condition. The first 



192 DENTAL PATHOLOGY. 

action of any injury, therefore, is to cause a tempo- 
rary paralysis of the muscular fibres in the wall of 
the blood vessels of the part exposed to the injury, 
and thereby allow an increased amount of blood to 
enter the vessels, and thus give a heightened color 
to the flesh, which color is recognized as one of the 
symptoms of a commencing inflammation, and is the 
first appearance noticeable to the eye. 

The second of the cardinal symptoms of inflam- 
mation consists in the elevation of the temperature 
of the part in which the inflammation is located. 
This phenomenon is intimately associated with the 
preceding one, and depends in a great measure upon 
it. The temperature of the interior of the body is 
always higher than is shown by the thermometer 
applied upon the outside of the body, which is cooler, 
owing to the loss of heat by radiation. The blood, 
therefore, in the heart and other large organs of the 
body is warmer than it is when it has reached the 
extremities, and has thus become somewhat cooled. 
If, now, the vessels of the extremities were enlarged, 
so as to allow a larger amount of blood to pass 
through them, the temperature of the part would be 
elevated, from the larger amount of warmer blood 
coursing through the vessels of the part. Thus we 
find the reason for a portion of the heat which is 
noticed in any part of the body which is the seat of 
acute inflammation. In some forms of disease, par- 
ticularly those of an infectious character, as in typhoid 
fever, the temperature of the entire body is much 
higher than normal, and the patient is said to have 
a " general " fever in distinction from a local eleva- 



INFLAMMATION. 193 

tion of the temperature in a particular portion of the 
body, due to some inflammatory action confined to 
this one part. 

• The third of the phenomena attending inflamma- 
tion is the swelling. This is due to two causes, viz., 
the hyperemia, or increased amount of blood in the 
part, and also to the leaking of the fluid part of the 
blood through the walls of the blood vessels into 
the tissues of the part affected, which is called the 
" effusion " of serum ; and this adds to the size of the 
organ or portion of the tissues which is the seat 
of the inflammation; and from these two different 
sources the main portion of the swelling, sometimes 
very great in amount, is derived. 

The fourth of the symptoms of inflammation, the 
pain, is the result of the previous phenomena. It is 
produced by increase of pressure in the part in which 
the inflammation is seated ; and results at times 
from a moderate amount of pressure, as in toothache, 
which is the result of increased pressure in the inte- 
rior of the tooth chamber, or at its root, which are 
both inclosed in unyielding walls, so that no expan- 
sion can take place, and the result is an immediate 
and painful pressure by the effusion or swelling 
upon the nerves of the tissues thus inclosed ; and the 
fourth symptom of inflammation, the pain, is thus 
produced. In some parts of the body in which the 
tissues are loose and yielding, as in the eyelid, the 
swelling may be very great in amount without caus- 
ing pain, because the tissues are able to stretch and 
to accommodate the fluid without sufficient joressure 
to cause pain. The same amount of effusion in the 



194 DENTAL PATHOLOGY. 

end of the finger, as in felon, would cause intolerable 
agony. The pain is actually caused by compression 
of the sensitive nerves of the part, and is more or 
less intense according as the effusion is more or less 
confined, and is, therefore, the cause of greater com- 
pression of the nerves which lie in the tissues of the 
inflamed area. 

To the symptoms of inflammation thus far enu- 
merated may properly be added one other — the sus- 
pension of function of the part affected. If the eye 
is the seat of inflammation, it becomes so sensitive 
to light that it cannot be used for seeing anything; 
if the tooth be inflamed, it is quite impossible to bite 
upon it on account of the pain which would thereby 
be caused; and if the finger be the seat of acute 
inflammation, it becomes painfully sensitive to the 
slightest touch. Thus we find that the function of 
the part inflamed is always seriously interfered with, 
and generally entirely suspended during the exist- 
ence of the inflammation. 

The particular features of the inflammatory pro- 
cess have long been the object of careful study by 
many pathologists ; but it remained for the late Prof. 
Cohnheim to discover the essential character of this 
most interesting condition. 

After long and diligent investigation, Prof. Cohn- 
heim was able to lay before the profession the tangi- 
ble and visible features accompanying the symptoms 
of the inflammatory process, and to explain the here- 
tofore unknown causes of these features. By the use 
of the microscope, he was able, after repeated trials 
upon rabbits and guinea pigs, to observe the changes 



INFLAMMATION. 195 

in the tissues, which had been so treated as to cause 
inflammation of these parts. The frog was finally 
found to be the most useful subject for experimenta- 
tion, and was the animal usually chosen for demonstra- 
tion. If the tongue of a frog be extended upon a glass 
slide, and be fastened there by means of small pins, 
so as to keep it spread out in a thin layer (the frog 
being under the influence of curare), the passage of 
the blood in the vessels of the tongue, both in the 
veins and in the arteries, may be observed with the 
greatest distinctness through the tissues of the unin- 
jured organ. The parts will be seen in a state of 
perfect health. If, now, a portion of the mucous 
membrane be removed by a fine scissors, and thus a 
wound of the surface of the tongue be produced, we 
shall at once have a condition of commencing inflam- 
mation, and shall be able to follow the changes thus 
inaugurated throughout their course, without the 
slightest trouble. The tongue should be kept wet 
with a solution of chloride of sodium, in order that 
the organ may not become too dry in the long expo- 
sure to which it is subjected, and thus the processes 
going on be either hindered or rendered inactive. 

The first change noticeable to the eye on removing 
the mucous membrane as has been described above, 
is that the incision gaps to a size larger than the 
piece of mucous membrane removed would seem to 
allow; that is, that there is active contraction in the 
wounded edges, so that the wound is made larger by 
the retraction of the border of the incision. This in- 
dicates that there is an active irritation at the seat 
of the lesion, which awakens an immediate response 



196 DENTAL PATHOLOGY. 

in the way of positive contraction of the wounded 
tissues. Soon the blood vessels in the area of the 
wound are seen to present marked changes in their 
appearance. These changes are first noticeable in 
the veins, and consist in a distinct enlargement of 
their calibre, by which they become great trunks, in 
which the current of the blood is slowed, on account 
of the larger size of the channel, and in which it 
comes at times to remain absolutely quiet. Usually, 
however, there is a continuous, though it may be a 
very moderate, movement in the blood current, so 
that it is not stopped in its' flow. With the enlarge- 
ment of the channel and the slowing of the current, 
there is associated a change in the composition of 
the current, In the ordinary flow of the blood there 
is no separation of the elements of the blood ; the 
stream is homogeneous. Now, however, there is soon 
observed to be a change in the composition of the 
blood current, There is a separation of the blood, 
so that the white corpuscles come to lie against the 
wall of the blood vessel, while the red corpuscles pass 
along the middle ol the vessel, and constitute the 
bulk of the moving current, the white corpuscles 
remaining comparatively stationary. At length there 
is a tendency among the white corpuscles to stick to 
one place upon the wall of the vessel, and no move- 
ment of the blood current is sufficient to remove 
them. Soon a portion of the white cell is seen to 
appear upon the outside of the wall of the blood ves- 
sel, and by a slow process this portion increases in 
size, while the part still within the blood vessel 
becomes smaller, until the entire corpuscle has" passed 



INFLAMMATION. 



197 



through the wall of the blood vessel, and is seen to 
lie in the connective tissue upon the outside, having 
migrated through the vascular wall, without leaving 
any visible orifice where it passed through. From 
this point the white blood cell now migrates still 




Cut showing the effect of a commencing inflammation upon the blood-current 
of the part The red corpuscles are collected in a central column in the middle 
of the vessel, while the white corpuscles tend to approach the wall of the ves- 
sel, and in some places are adherent to it, and have already begun to throw out 
fantastic prolongations like the petals of a lily, or irregular elongations which 
indicate the commencement of migratory movements. At A and B the cells 
have penetrated the wall of the channel, and are on the outside of the vessel, 
and moving away into the tissues. The cut represents the blood of the frog, 
but can only faintly indicate the beauty of the process of cell-migration as 
seen under the microscope. 



further in the tissue toward a free surface; and at 
length appears upon the wounded surface, from which 
it may be removed by gently touching it with a 
camel's-hair pencil : and the blood cell which was a 

17 



198 DENTAL PATHOLOGY. 

short time before in the veins of the animal, is free, 
and outside of the body of the animal. 

In an extensive inflammation the process here 
described is carried on to a surprising degree, and the 
number of cells thus passing away is very large, so 
that a considerable discharge of yellowish creamy 
substance takes place from the seat of the injury, 
which is called "pus." Thus, we see that so-called 
"pus " is due, in great part, to the exudation or migra- 
tion of white blood cells from the inside of the blood 
vessels, through their uninjured walls, and thence to 
the surface of the inflamed spot, where these same 
cells are discharged as a fluid, which has long been 
recognized, but the composition of which was not 
distinctly understood. There are, also, other compo- 
nents of pus, but the essential elements are the serum 
which is exuded from the tissues, and the white cells 
of the blood, which are due to the migration of the 
corpuscles through the walls of the vascular channels. 
Here we find the reason for the increase in the swell- 
ing accompanying an acute inflammation which has 
lasted for some hours or days, in which the processes 
of exudation of serum and the migration of the white 
corpuscles has been going on activety, until the entire 
tissue of the part is filled with these products of 
migratory action, and the mass of the part is much 
increased in volume ; so that there is a large and hard 
spot at the seat of the inflammation, which is called 
the inflammatory "induration." The irritation of 
the inflammatory process also causes increased growth 
in the natural tissues of the part affected, and the 
entire organ may thus be enlarged, as is seen in an 



INFLAMMATION. 199 

old and long-standing abscess of the jaw, in which 
the entire bone of the jaw has become thickened, and 
is found to present a large and hard lump at the site 
of the disease ; which often subsides only very slowly, 
if it is ever wholly removed. 

The occurrence of suppuration, as has just been 
shown, is accompanied by the passage of large 
numbers of white blood cells from the interior of 
the blood vessels into the tissues, and thence to 
the surface, which has either been injured, or in 
some way has become the seat of inflammatory 
action. There are, however, other elements associ- 
ated with suppuration, which arise in part from 
the intensity of the disturbance in the region of the 
inflammation, but are also in part accidental. Those 
which are due to the disturbances of the part are of 
the nature of destruction of portions of the normal 
tissues of the region, and are caused, to a great extent, 
by the unusual pressure which exists as one of the 
consequences of the inflammation. Destruction of 
tissue may also be produced by disturbance of the 
blood supply, by which the nutrition of the part 
may be seriously impaired, and loss of vitality, or 
gangrene be thereby induced. The products of dis- 
organization of the tissues from any cause are thrown 
oil from the body as rapidly as possible, and if sup- 
puration already exists in the vicinity, they generally 
find their way into the discharge, and are thus mixed 
with the pus. Portions of muscular fibre, particles of 
connective tissue and other structures are, in this way, 
often associated with a purulent discharge, although 
they properly form no part of the pus, strictly 
speaking. 



200 DENTAL PATHOLOGY. 

To these constituents of the discharge from an 
inflamed part are to be added accidental admixtures 
from external sources, such as the various forms of 
bacteria, the coloring matters sometimes found in 
pus, and the other foreign substances occasionally 
observed in the vicinity of suppurating wounds. 
These various admixtures are mentioned in this con- 
nection because they are often observed in relation to 
wounds, especially when these are not in a cleanly 
or healthy condition, and sometimes the contamina- 
tions of pus are the most important factors in the 
progress of the lesion toward recovery, or toward 
further destruction of the tissues and the extension 
of the disease. 

We have thus far considered inflammation only in 
relation to those parts in which there is an abundant 
and continuous blood supply. It might be thought 
that the phenomena of inflammation would be dif- 
ferent in those parts in which the blood supply either 
is limited in amount, or in which there is no vascular 
circulation. The latter is true in the cornea, which 
is a transparent structure, entirely without blood ves- 
sels, when in a condition of health. If now the 
centre of the cornea becomes the seat of an injury, 
causing inflammation, there will be a variation from 
the series of symptoms detailed above, to correspond 
with the changed conditions in the normal structure 
of the tissue affected. 

The cornea being without blood vessels, it is plain 
that there could be no immediate dilatation of blood 
vessels in the area of the injury. Experiments, how- 
ever, have proved that the general outline of in flam- 



INFLAMMATION. 201 

mation in the corneal tissues is the same as that in 
other and vascular structures. If the centre of the 
cornea be touched with a heated needle (and this is 
the best way of inducing a traumatic inflammation, 
for several reasons), there is no reaction at the imme- 
diate seat of the injury; there is pain, because the 
sensitive nerves of the cornea have been cauterized, 
and the structure of the cornea is destroyed to a cer- 
tain degree. The symptoms of inflammatory reac- 
tion, however, are observed at the edge of the cornea, 
at that point which is nearest to the seat of the injury ; 
at which point there is observed, almost immediately, 
an enlargement of those blood vessels which were 
before visible, together with the appearance of numer- 
ous other vessels which were not before to be seen. 
At once there is a stagnation of the blood in these 
large vessels, the migration of the white blood cells 
begins, there is swelling of the conjunctiva, and the 
signs of an intense activity of the inflammatory 
action. Soon a wedge-shaped point of grayish opaque 
character appears at the edge of the cornea nearest 
the injury and slowly advances toward the point at 
which the injury was inflicted, and when, after some 
hours, it has reached the seat of the injury, it comes 
to the surface, and is seen to be composed of white 
cells of the blood, consequently pus, which has been 
conveyed from the nearest point at which blood ves- 
sels are distributed, and has appeared at the distant 
seat of injury in the cornea. Soon after this time, 
fine blood vessels are seen to extend on to the cornea, 
and finally to reach the point of injury, when the 
process of migration of white cells goes on even 



202 DENTAL PATHOLOGY. 

more rapidly than before. Thus we see that in an 
acute inflammation there is a formation of not only 
additional substance in the part affected ; but in the 
eye at least, there is a production of new organic 
structures in a part in which no such structures nor- 
mall} 7 belong. When the process of healing has 
been completed, these new vessels disappear, and 
when the eye is at length well, no trace of these ves- 
sels can be detected. In the structure of cartilage, 
again, there is no normal blood circulation, but in 
inflammation of this structure there is a prolongation 
of the vascular supply from the nearest point, so that 
at length the seat of inflammation is found to possess 
a vascular network, and to be supplied with blood. 



COURSE AND PROGRESS OF INFLAMMATION. 203 



CHAPTER XXV. 

COUESE AND PEOGRESS OF SYMPTOMS IN ACUTE 
INFLAMMATION. 

The cause of the successive phenomena attending 
inflammation has long been a subject of speculation, 
but the most recent investigations seem to point to 
the following explanation : At the time of the injury, 
there is a shock of greater or less intensity to the 
nervous structures supplying the part affected. The 
first intensity of the injury and its first effect is devel- 
oped in the nerves of the part, which are, for the 
time, deprived of their activity, and lose their func- 
tion. This is especially applicable to the nerves 
distributed to the vessels, the so-called vaso-motor 
nerves, which control the degree of contraction of the 
muscular- fibres of the coats of the blood vessels, and 
thus regulate their calibre. The effect of the tem- 
porary paralysis of these muscular fibres is the imme- 
diate dilatation of the vessels to their fullest capacity, 
and thus they receive a much larger amount of 
blood than under ordinary circumstances, and mark 
the redness of commencing inflammation. 

The pressure of the blood within the walls of the 
vessels is notably increased under this condition, 
from the fact that the larger calibre of the vessel in 
the area of the inflammation is the cause of increased 
internal pressure, from the same cause as operates in 
the hydrostatic pump, that is, that the passage of the 



204 DENTAL PATHOLOGY. 

current of blood from a smaller channel into a larger 
one is accompanied by an increase of tension in the 
walls of the larger vessel. The dilatation of the 
lumen of the vessel must be accompanied by a 
diminution in the thickness of its wall, as the tissues 
of the vascular wall are spread over a larger surface, 
and thus the actual resistance to the passage of fluids 
out of the vessel is notably diminished. This fact 
may also have something to do with the migration 
of the white blood cells, but this is not proven, as 
the passage of these bodies through the wall of the 
blood vessels seems to be an organic activity, and not 
the result of a variation in the mechanical resistance 
of the tissues. This entire subject is not yet satis- 
factorily decided, but many features still remain for 
elucidation by future observers. In dental pathol- 
ogy there is especially a field for clinical and experi- 
mental work, in the investigation of inflammatory 
and other diseased and destructive processes. 

The cause of inflammation is not always the same, 
for the conditions under which it arises are variable, 
and the locations of origin are widely different, In 
the description above given, the cause of the inflam- 
mation was supposed to bean external injury. This 
is, however, but one of the occasions under which 
inflammatory conditions may arise. A more fre- 
quent cause, at least in the region of the mouth and 
teeth, is found in the disturbance of the nutrition of 
the part or organ, by some interference with its blood 
supply, the stoppage of which causes the death of 
the part from which the blood is cut off. This acci- 
dent produces a condition in some ways the oppo- 



COURSE AND PROGRESS OE INFLAMMATION. 205 

site of that which was described above. There is in 
this case a portion, of tissue in the interior of some 
organ which has lost its vitality from lack of nutrition, 
and is transformed into a larger or smaller mass of 
dead tissue; which is now only a foreign body, for 
which the system has no use, and which nature 
immediately endeavors to cast out of the system. 
The seat of irritation is not situated upon a free sur- 
face, but is located in the midst of healthy or, at 
least, vitalized, tissues. This form of inflammation 
may be illustrated by the history of a common felon 
upon the end of the finger, which corresponds in all 
essential conditions to an acute inflammation situ- 
ated in any other resisting portion of the system. 
In felon, the inflammation commences by a slight 
sensation of pain in the end of the finger, which is, 
ordinarily, so indistinct that its exact location cannot 
be recognized, but the sensation is one of ill-defined 
pain and tenderness. Soon the pain becomes more 
pronounced, and at length the agony is something 
beyond description. If no treatment is instituted, 
the finger is finally much swollen and breaks at some 
part of its surface, discharging a large amount of 
pus and broken-down tissues, together with a portion 
or the whole of the bone of that phalanx of the 
finger ; or the inflammation may follow the course 
of the tendons up the finger, into the hand, or even 
to the forearm, which then becomes the seat of exten- 
sive suppuration, causing large abscesses, which 
sometimes render amputation of the arm necessary, 
or even destroy the life of the patient. In a felon, 
the seat of the primary irritation, the insult, the first 

18 



206 DENTAL PATHOLOGY. 

cause of the inflammation, is located in the deep 
part of the finger, often in the sheath of the tendon 
or in the periosteum covering the bone. The phe- 
nomena of commencing inflammation occur in the 
same way here as when the seat of the injury is 
located upon the outside of the body, but the parts 
are firmly bound down by strong membranes which 
do not allow any distention of the tissues to ac- 
commodate the increased amount of blood, serum, 
etc., which crowd into the inflamed part. The con- 
sequence of this is, that the effusion of serum, white 
corpuscles, etc., is the cause of enormous pressure 
upon the parts around, the nerves of the tissues are 
greatly compressed and the pain is intense. The 
pressure also closes some of the blood vessels of the 
neighborhood .by pressing their sides together, and 
this also interferes with the nutrition of some por- 
tion of the tissue near the seat of the inflammation. 
The result of all this is, that in the deep parts of the 
finger there is a fragment of flesh which has been 
deprived of its vitality, and has undergone a process 
of disintegration called Necrosis. The flesh may be 
quite dissolved, or it may be found as a ragged mass 
of grayish color and shreddy appearance, which is 
found at the bottom of the wound if the felon be 
opened in due time, or is cast out at the opening 
which occurs after a longer time, if the finger be 
left alone. This shred of dead tissue is recognized 
as the slough, or a portion of the finger which has 
died from lack of nutrition, and is called by the 
common people the " core." An abscess is not 
thought by the laity to be in condition to heal until 



COURSE AND PROGRESS OF INFLAMMATION. 207 

the " core " is discharged, when it is rightly supposed 
that the cause of the inflammation has been removed 
and healing of the part may occur. 

There is, therefore, an additional feature in the 
history of deep-seated inflammations, consisting in 
the existence of a centre of irritation which is formed 
in some part of the normal tissues of the organ, 
either of the hard or the soft structures ; which is 
devitalized from some cause, and is thereby trans- 
formed into a source of inflammation, has become a 
foreign body, which nature cannot use, but tries to 
remove from the body, as would be the case were a 
splinter of wood or a fragment of iron to be lodged 
in the body. When the slough is at length gotten 
rid of, the process of recovery may commence, and 
the part may at length be restored to its original 
condition ; or the amount of damage caused by the 
inflammation may have been so great that perfect 
restoration may not be possible, and a greater or less 
degree of deformity remains after healing is com- 
plete. Frequently there is a mark at the seat of the 
inflammation, which is of different color from the 
surrounding skin, and is called the scar. This may, 
after a time, become invisible, but frequently it 
remains as a permanent condition during the life of 
the individual. 



208 DENTAL PATHOLOGY. 



CHAPTER XXVI. 

INFLAMMATION OF HARD STRUCTURES AND OF THE 
TEETH. 

The inflammatory process is not always confined 
to the soft tissues, but may extend to the hard struc- 
tures, such as the bones and teeth. Here it is not 
the calcareous portion of the bony material which is 
affected, but it is the soft connective tissue whick 
penetrates every part of the bone, which is the actual 
seat of the inflammation ; or it may be that the peri- 
osteum which covers the bone on its outer surface is 
the part which is affected. However this may be, 
the inflammation generally extends into the bone 
itself to a greater or less degree, and b} r the pressure 
and other phenomena above explained, causes the 
death of a part- of the bone, with its contained con- 
nective tissue, vessels, etc. This forms a foreign body, 
just as in the inflammation of the soft tissues, we find a 
slough. The portion of bone which is deprived of 
its nutrition might be called a slough of bone, but 
the common name given to such a portion of one of 
the bones is that of Necrosis. Necrosis means really 
nothing but " dead tissue," and thus far the name 
is not well chosen, but it has become familiar to 
dentists in relation to dead bone, rather than the 
same condition in the soft tissues, until it is now fre- 
quently understood to refer only to the hard tissues. 
In inflammation of the bony structures, the same 



INFLAMMATION OF THE TEETH. 209 

process is at once started, as is the case in the soft 
parts, in the way of dilatation of the blood vessels, 
exudation of serum, the migration of the white blood 
cells, and the obstruction of the circulation. The por- 
tion of the bone which has become necrosed is slowly 
separated from the living tissue around it, and is at 
length cast off from the healthy portion; when heal- 
ing of the part may take place, as in those cases in 
which the inflammation affects the soft tissues. 
When the inflammation is seated in bone, the pro- 
cesses of separation and repair are much more slowly 
carried out than in the soft parts, owing to the dense 
character of the structures involved, but the process 
is of exactly the same character as in the soft tissues. 
When the bone has become separated from its at- 
tachment to the surrounding parts, it is often retained 
in place, from the fact that its size and firm structure 
prevent it from being so easily thrown out of the sys- 
tem as the soft slough of an ordinary abscess may 
be. We, therefore, find the portion of bone in many 
cases lying loose in the cavity of the abscess, where 
it is being slowly disintegrated by the action of the 
tissues around it, until it becomes so broken up that 
the particles may pass through the channel made by 
the escape of the pus, when, after all the portions of 
bone have been extruded, the place may heal entirely. 
The loose portion of bone in these cases of necrosis 
is called a sequestrum. In some cases it may be 
only a small part of one of the bones of the finger, 
or it may comprise the entire shaft of one of the 
long bones of the limbs. This affection is frequently 
observed in the region of the teeth, in the alveolar 



210 DENTAL PATHOLOGY. 

process of the upper or lower jaw, in the vicinity of 
the antrum, or it may be situated upon the inferior 
surface of the hard palate, from which situation it 
may extend over a large portion of the roof of the 
mouth. In these various locations the necrosis may 
be due to very different causes, among which may 
be mentioned caries of the teeth, inducing destruc- 
tion of the neighboring alveolar process ; injury, such 
as fracture of the jaw ; the effect of certain poisons, 
particularly phosphorus ; the result of some of the 
(•(institutional diseases, among which may be promi- 
nently mentioned syphilis; the invasion of the parts 
by cancerous or other malignant growths, and the 
occasional result of the presence of lead or mercury 
in the system. 

From whatever cause the necrosis may have been 
produced, the conditions in the part affected are 
almost always similar. The dead portion of bone is* 
at first retained in the location where it was formed ; 
a swelling of the soft parts covering the seat of the 
disease takes place, and the formation of pus occurs 
in the way above described. ' After a time the mem- 
brane, or, if on the outer surface of the body, the 
skin becomes distended and thinned, and at length 
an opening is formed through which the accumulated 
matter escapes. At the bottom of the opening thus 
formed, we may feel the denuded surface of the dead 
but still immovable bone, as a rough and grating sur- 
face, from which the periosteum is absent, and which 
is bathed in the purulent fluid which is discharged 
from the wound. 

The examination of a part which is the seat of 



INFLAMMATION OF THE TEETH. 211 

disease, to ascertain if necrosis exists, is not always 
easy, on account of the fact that the channel leading 
down to the necrosed bone is often of a winding or 
devious character and cannot be easily followed. For 
the purpose of such an examination, the best means 
is by a long and slender probe, with which we gently 
penetrate the canal, and by curving the probe, follow 
the curves of the passage until we reach the portion 
of bone at its deepest part. The probe should be held 
very lightly by the fingers, and should be manipu- 
lated with the utmost care and gentleness; it should, 
in reality, form only a prolongation of the fingers, 
and should serve to convey an exact idea of the 
nature and character of the tissues with which it is 
in contact at any part of its course. The impression 
made by the impact of the end of the probe with 
denuded bone is a peculiar one, and one not easy to 
describe by words. It is not always the same, but is 
different, according to the character of the bone 
affected, whether this be of dense or loose structure, 
and also, to a certain extent, varying in correspond- 
ence to the time during which the necrosis has ex- 
isted. 

The presence of an inflammation in the near 
vicinity of a bone is not always followed by necrosis, 
but may sometimes give rise to increased growth of 
the tissues in the vicinity of the bone, which increase 
in growth usually affects the fibrous structures, such 
as the periosteum or the connective tissues ; so that a 
thickening of these structures takes place and their 
volume is materially increased by the new formation 
which thus follows, as a consequence of the irritation 



212 DENTAL PATHOLOGY. 

caused by the proximity of the inflammation. This 
effect is often observed in the vicinity of a chronic 
inflammation of the alveolus; as well as in some 
cases of slow and prolonged inflammation of the 
root of a tooth, in which the activity of the in- 
flammatory process is not sufficiently marked to 
produce the phenomena of acute inflammation of 
the alveolus; but the whole process is very slow 
and gradual, and requires weeks or months for 
its course. At the end of tins time we may often 
feel an enlargemenl of the bone at, or over the seat 
of the inflammation, where there is an actual in- 
crease in the thickness of the hone or of the peri- 
osteal covering, due to irritation from the inflamma- 
tory process which lias been carried on near it. This 
increase in the size of the bony tissue when it 
is permanent is railed an "exostosis" or a "hyper- 
ostosis" upon the surface of the hone; and when it 
affects the sofl tissues it is usually called a "hyper- 
trophy" of these tissues. The word "hypertrophy" 
means -imply an overgrowth of any of the tissues of 
the body, but it is generally understood to apply par- 
ticularly to the soft tissues, while the terms "exos- 
tosis" and "hyperostosis,'' relating to bone, apply 
only to the hard tissues. The same general pro- 
cess of increased growth here described, takes place 
in the healing of a fractured bone, during which 
there is a large amount of extra material thrown out 
about the point of injury, which envelops the seat of 
the fracture, covering the ends of the broken bone, 
and thus uniting them by an external growth of new 
tissue about the seat of the injury, much in the way 



INFLAMMATION OF THE TEETH. 213 

in which a plumber unites the ends of lead pipes 
by placing a large elongated fusiform mass of lead 
around the ends, which unites them in a perfect joint. 
After the broken bone has fully healed, the mass of 
callus, as the extra material which is thrown out at 
the ends of the broken bone is called, and which first 
unites the fracture with a mass of soft substance 
much as putty would unite a rod of glass which 
had been broken, which, in fracture, forms the first 
means of union between the ends of the fractured 
bone, is gradually absorbed and carried away ; so that 
after a time there is no trace of this substance to be 
found at the place where the bone had been broken. 
Nature removes the extra material as soon as there 
is no further need of it, and the parts are restored to 
their former condition. In the case of new forma- 
tion of bone, however, as the result of a long-stand- 
ing irritation, there is no such prompt effort at 
removal of the new formation, but the mass of extra 
material is permanent, and remains so during the 
lifetime of the patient. As a result of this, we often 
see nodules of new bone attached to many of the 
bones of the body, which have been formed by the 
action of some inflammatory process and have never 
changed afterward. This is frequently remarked 
upon teeth which have been the seat of pain or other 
signs of subacute inflammation at a period long 
anterior to their extraction, and which, on being 
removed from the jaw, show large club-shaped pro- 
tuberances from the root surface ; or the entire root 
may have been changed into a thick and knobbed 
mass of bony tissue, in which all resemblance to the 



214 DENTAL PATHOLOGY. 

normal shape of the root of the tooth is utterly lost. 
At times the existence of a long-continued, low, sub- 
acute form of inflammation in the vicinity of the 
root of a tooth will cause the formation of an enlarge- 
ment upon the outer surface of the jaw, which will 
persist through the life of the individual, though it 
may, in some cases, be somewhat reduced in size as 
time passes. In other cases, the irritation or other 
causative agent may be confined in its action to a 
limited area situated upon a circumscribed portion 
of the root of a tooth, or other portion of the dental 
apparatus, when the effect will be observed in the way 
of an hypertrophy or increase in the size of the part 
which was the seat of the irritative process. This 
often produces the strangest results in the way of 
deviations in the shape of the teeth or of some por- 
tion of their structure, at times causing a deformity 
in their roots, in other cases causing a malformation 
in some of the other features of the tooth structure, 
which may remain unchanged for any length of time 
after it has once been produced. 

Thus the results of inflammatory action may vary 
according as the inflammation is of acute and violent 
character, or is of a more moderate degree of intensity 
and progresses more slowly. The first is usually fol- 
lowed by a sudden interference with the integrity of 
the tissues of the part which is the seat of the inflam- 
mation, and with a serious disturbance of its nutri- 
tion ; both of which operate to the detriment of the 
tissues, and lead to their serious impairment; and not 
infrequently to their destruction, by the processes of 
necrosis, suppuration and ulceration, with loss of a 



INFLAMMATION OF THE TEETH. 215 

certain amount of the normal material of the part. 
This may be more or less completely restored by 
the processes of repair which are associated with the 
healing of these lesions in many parts of the body. 
Recovery is often unaccompanied by any of the 
signs of destruction of the tissues, but, on the con- 
trary, the inflammatory process has the power to 
awaken new and unusual growth in the tissues 
affected, by which their volume is augmented and 
their character often changed, as when the tissues are 
rendered brawny and thickened. In a chronic alve- 
olar abscess, the thickness of the alveolus may be 
greatly augmented as the result of the irritation of 
the periosteum and other adjacent tissues, by which 
increased growth of these structures and an increased 
amount of their products is produced. In any study 
of these processes it is essential to remember that the 
irritation of a certain tissue is not necessarily fol- 
lowed by an increase in volume of that particular 
tissue, but that the increase may, perhaps, be in the 
substance of some other tissue or structure. Thus, 
the irritation of the periosteum, when this is not of 
too acute form, has for its principal result, not an 
augmentation of the periosteum but the deposition 
of increased amount of bone, so that a bony tumor 
is at length formed, of greater or less extent, either 
in the shape of a considerable enlargement at a cir- 
cumscribed part, or it may be in the form of an 
extended fusiform increase in size of the part which 
was the actual seat of the inflammatory process, and 
of the adjacent bony texture as well. The increase 
in the contour of the jaw from hypertrophy may be 



216 DENTAL PATHOLOGY. 

followed by an absorption of the bony tissue in some 
other part of the jaw, and a change in the bone may 
thus be brought about which will at length greatly 
alter the appearance of the facial outlines, and be the 
cause of actual deformity to the individual. This 
gradual transformation is sometimes productive of 
change in the location or the direction of the teeth, 
which may become extruded and lost, from absorp- 
tion of the bone about their roots, and in this way 
the changes in the nutrition of the bone, which 
were brought forth by the inflammatory process 
may produce a lasting detrimental effect upon the 
denture of the individual. The hyperplasia of 
bony tissues may have still another effect upon the 
nutritive changes in the part, from the fact that the 
new formation of bone often takes place in or around 
the channels in which the blood vessels and nerves 
of the bones are contained. Any new deposition of 
bone within the canal which contains such an im- 
portant structure as an artery, a vein or a nerve must 
seriously interfere with the function of these organs 
in the way of a greater or less disturbance of the cir- 
culation, or the nervous supply in that part to which 
the blood vessels or nerves are directed. This may 
be so serious in degree that the integrity of the part 
is affected, and the organ which is thus deprived of 
some portion of its nutritive supply may undergo a 
gradual retrogressive change, called atrophy, in which 
the tissues, especially the soft tissues, become dimin- 
ished in volume, weakened in structure, reduced in 
texture and enfeebled in function ; and may at length 
entirely disappear, from the absorption of the atro- 



INFLAMMATION OF THE TEETH. 217 

phied and degenerated remains of the former struc- 
tures, which have been deprived of their proper 
nutrition by the partial closure of the channels of 
their blood supply or of their nervous distribution, 
from interior exostoses. 

Far more frequently than the degeneration of the 
tissues, as the result of exostosis, is the occurrence of 
pain in the parts to which the nerve which passes 
through the canal is directed. The pressure upon the 
nerve trunk causes a sensation of pain in those parts 
in which it is distributed, and the pain is often of most 
acute character, being one of the well-recognized forms 
of neuralgia, or pain in the nerve. With this, there 
may be no atrophy, and it is a fact that most acute 
suffering from neuralgic pain may often be endured 
a long time without perceptible effect upon the volume 
of the tissues or upon their functional integrity, their 
only impairment being such as may be due to the in- 
terference with their proper functions which is occa- 
sioned by the excessive pain. 

Occasionally the progress of a chronic inflamma- 
tion is accompanied by the formation of an abscess, 
situated at or near the seat of the original inflamma- 
tion and due to it. The abscess is filled with a puru- 
lent fluid, the character of which does not materially 
differ from that found in an acute abscess, such as is 
described in a previous chapter, except that the sup- 
puration which occurs as the result of a chronic 
abscess is noticeably more consistent than that from 
an acute abscess; that is, the pus in an acute and 
rapidly-formed abscess contains more fluid than that 
in a chronic abscess. There is also less febrile action, 



218 DENTAL PATHOLOGY. 

less heat of the surface, less reaction in any way, and 
the entire process is less energetic and less vivid in 
all respects. On this account, this variety of inflam- 
mation, with its following abscess, has given rise to 
the designation of the process as a " cold abscess." 
The processes in this variety of abscess are doubtless 
of the same degree of severity as in a so-called " acute " 
abscess, but being distributed over a longer period of 
time, they at no time present the same degree of vio- 
lence as do the symptoms of an acute inflammation. 
One of the results of chronic inflammation may be 
the slow formation of deposits of purulent fluid, 
which may remain for a long time in a quiescent 
state, and may never come to the surface so as to be 
discharged, but are retained in the tissues where first 
deposited, giving no indications of trouble from their 
presence. The pus thus imprisoned gradually loses 
much of its fluid portions, and at length is reduced 
to a cheesy mass, which may at times contain small 
lunrps of calcareous material, and then is called 
cheesy pus, or calcified pus. Such deposits, or the 
remains of former inflammations, are often found in 
post-mortem examinations of persons who have died 
from the most various causes, but who at some former 
time ma}^ have suffered from a slow and lingering 
inflammation, which had led to a formation of pus, 
which then underwent the process of thickening as 
above described, with the result that the cheesy resi- 
due of the suppuration had been retained for a long 
period within the system of the patient, where it did 
no further harm. Such deposits may be observed in 
the lungs, in the neighborhood of the lymphatic 



INFLAMMATION OF THE TEETH. 219 

glands, and frequently in other not so common 
situations. It was at one time thought that the 
presence of inspissated or cheesy pus in the body 
was a predisposing cause of tuberculosis, but this 
theoiy is no longer maintained by the most able 
pathologists; and tuberculosis is now believed to 
depend upon the presence in the body of a certain 
bacterial organism, the bacillus tuberculosis, which 
has no constant or definite relation with purulent 
deposits as causative factors in their existence, or 
their appearance in any case of that disease. 



PART VI. 



CHAPTER XXVII. 

TATHOLOGICAL AND MALIGNANT GROWTHS 
(TUMORS). 

Among the conditions associated with the path- 
ology of the oral cavity and its surroundings, none 
are more interesting than those relating to the new 
formations which are observed there. These may 
be of two general varieties, the benignant or harm- 
less, growths, and the malignant or destructive 
growths. In general terms, any enlargement of a 
part, if it be of a circumscribed character, and par- 
ticularly if it be elevated above the natural level of 
the surrounding parts, is called a tumor, so that 
these new formations would be ranked in the cate- 
gory of Tumors. 

One of the chief qualities of any pathological 
formation resides in the character of the tissue of 
which it is composed. It may be formed from an 
excessive production of the normal tissues of the 
part, and thus not be in histological character in any 
way different from the textures surrounding it, and 
is only a pathological condition in respect to the 
amount and arrangement of the ordinary materials 
of which the region in which it is situated is com- 
220 



PATHOLOGICAL AND MALIGNANT GROWTHS. 221 

posed. Such a new formation is said to be a " homo- 
logous " growth, that is, a growth of character 
similar to that of the normal tissues. These growths 
form a large proportion of all the pathological forma- 
tions of the body, and include in their number the 
great class of hypertrophies, the exostoses, most of 
the congenital tumors, and many growths of varying 
origin, such as the arthritic enlargements following 
a rheumatic attack, or the chronic enlargements 
which are produced by long-continued irritation of 
a part or organ. 

The other division of new formations is called the 
heterologous class, in which the character of the 
growth is histologically different from that of the 
tissues surrounding it ; in which it is situated ; or 
with which it is in contiguity or continuity. 

The growths belonging to this class of formations 
may be produced by a variety of causes. Among 
these, the element of heredity occupies a large place, 
and to this element is due a great proportion of this 
variety of pathological formations. To these growths 
also belong another peculiar feature, which is of the 
greatest importance ; that is, that they often contain 
within themselves the element of malignancy, by 
which is understood a tendency to operate by their 
continued existence, in such a way as to cause the 
destruction of the parts or organs in which, or near 
which they are situated, either by invading their 
substance and thus displacing them, causing their 
atrophy or their absorption ; or by the occurrence of 
new formations of the diseased pathological growth 
in the vicinity of the first formation, either by direct 

19 



222 DENTAL PATHOLOGY. 

transplantation, owing to the continued growth of 
the first centre of disease ; or from the transference of 
the material of which the new growth is formed, by- 
means of the blood or other channels, to new and 
sometimes distant locations. The same process is 
here carried out, as in the original location of the 
first spot in which the disease manifested itself. This 
process is called " metastasis," and these secondary 
productions are called metastatic growths. They 
may occur in near proximity to the first growth, or 
they may arise at a distance from the seat of first 
invasion, according to the conditions under which 
the metastasis has occurred. 

To this latter class of pathological formations 
belong the various growths which have been classi- 
fied as " cancerous." This appellation is not a fortu- 
nate one on many accounts, but it is mentioned 
because it has become fixed in the literature, and is 
understood to embrace those pathological formations 
which have a tendency to increase in size, to invade 
the domain of other organs, and to occupy their 
place ; and, most of all, these growths have the habit 
of breaking clown into some lower form of growth, 
or of undergoing processes of sloughing or other 
forms of necrosis, so that there is sooner or later a 
process of ulceration or gangrene in the substance of 
the pathological growth, with which is always associ- 
ated a greatly increased amount of danger to the life 
of the patient. 

The true distinction which should be made in 
relation to all pathological growths is one depending 
upon the tissues of which they are composed, a dis- 



PATHOLOGICAL AND MALIGNANT GROWTHS. ZZo 

tinction resting on histological formation rather than 
upon gross external appearances or upon clinical 
peculiarities. The element of malignancy is depend- 
ent upon several distinct pathological conditions, 
which have their rise in the circumstances of loca- 
tion, histological structure and accidental accessory 
conditions surrounding the pathological formation. 
These latter may consist in the degree of vascularity 
of the part, in the density of the tissues, whether 
they be of soft or firm consistency, in the degree of 
exposure to injury, or to heat and cold to which the 
part is subject, or to other and variable conditions. 

The great and only true distinction in pathological 
growths, however, consists in the character of the 
tissue-elements of which the growth itself is com- 
posed. This is ascertained by means of the micro- 
scope, and upon this depends to a very great extent 
the correct estimation of the nature and tendency of 
any pathological formation in the human body, both 
in relation to its effect upon the tissues with which 
it lies in direct contact, as well as its influence upon 
the well-being of the individual. 

Generally speaking, those growths which consist 
under the microscope of a superabundant develop- 
ment of the normal tissues of the part, an over- 
growth, or an unusual enlargement of the amount 
of some particular element, are of harmless character, 
and only produce signs of trouble from the increase 
in the size of the part, from weight, from pressure, or 
from the distorted appearance of the portion of the 
body which is the seat of the pathological growth. 
To this category belong the various congenital 



224 DENTAL PATHOLOGY. 

tumors, by which is meant those which are born 
with the patient, increase in size in a ratio corre- 
sponding with the growth of the patient, and are 
not the cause of apprehension from any tendencj^ 
to change into any other form of growth, or from 
any danger to the life of the individual, on account 
of malignancy. To such pathological growths are 
reckoned the fatty tumors (lipoma) which arc so 
often observed upon various parts of the body, and 
which rarely exhibit any tendency to undergo 
changes to other forms of tissue, or to in any way 
vary from the original character of the growth. 
Sometimes these tumors reach an enormous size, and 
from their weight become an insupportable burden, 
and for this reason the}'' are often removed by surgi- 
cal operation. At times the fatty growth interferes 
with the movements of the limbs, preventing the 
patient from sitting in a chair when the tumor is 
situated upon the hip, or producing an unsightly 
deformity when located upon the neck, face or head, 
and then it is frequently removed for convenience or 
for purely cosmetic reasons. The growth itself, how- 
ever, is usually quite free from any malignant ten- 
dency, is homologous in structure, and benign in 
character. Fatty tumors do not tend to invade 
other surrounding structures or tissues, nor are they 
liable to form new tumors in other parts of the body, 
such as some of the more dangerous growths are 
observed to do. In the fatty tumor we have an 
example of a simple, non-malignant growth, which 
may last indefinitely without danger to the patient 
from any change in the character of the growth, 



PATHOLOGICAL AND MALIGNANT GROWTHS. 225 

and which is attended only with the inconveniences 
associated with its size, its weight and its effect upon 
the convenience and appearance of the patient. 

Other examples of simple and harmless growths 
are seen in the common wart, which is so frequently 
observed upon the hands of many persons, and 
which has the added peculiarity of disappearing at 
times, and recurring after an interval either upon 
the same spot or in the near vicinity. The ordinary 
mole, or " mother's mark," is another variety of con- 
genital growth, of pathological character, ■ which is 
usually of innocent nature, although in some in- 
stances there is seen a tendency in these growths to 
change to some other form of tissue, and with this 
change is associated an increased tendency to malig- 
nancy. The rheumatic enlargements which are 
observed about the joints, or in other situations in 
persons who have long been subject to this disease, 
are the result either of the continued inflammation 
of the joints affected, which have become thickened 
in consequence, or they are due to the deposition in 
or about the joints of a mass of chalk-like material, 
composed in part of some of the elements which 
should have been removed from the body by the 
kidneys, and which form concretions in the cavity 
of the joints, thus causing a deformity of the 'parts, 
and often affecting the motion or at least the freedom 
of action of the articulation. 

At times the hard tissues are the seat of enlarge- 
ments upon their exterior or within their interior, in 
which their form may undergo material change and 
■their function may become perverted. Thus we 



226 DENTAL PATHOLOGY. 

sometimes observe exostoses upon the upper or lower 
jaw, or find that bony growth has encroached largely 
upon the cavity of the mouth from its pathological 
development into the buccal space; or it may pro- 
duce other not less marked variations from the nor- 
mal condition. 

Some of the tumors associated with the hard tis- 
sues are of parasitic origin, and are of contagious or 
infectious character. Thus, there is a disease called 
Actinomycosis, which was first observed, and studied, 
upon the lower animals, especialty upon cattle ; which 
has, as one of its characteristic appearances, the enor- 
mous enlargement of the lower jaw, with the subse- 
quent occurrence of ulceration, and the loss of the 
teeth and the destruction of the tissues in the region 
of the pathological growth. This disease has been 
observed in the human subject by Prof. Ponfick, of 
Rostock, and is thought to have been transmitted to 
man from the lower animals. 

Certain classes of new growths possess a peculiar 
property of invading the parts in proximity to their 
seat, and thus extending into the surrounding tissues, 
which are displaced by the advance of the patho- 
logical growth, are absorbed, from its pressure, and 
are replaced by the new formation. These tumors 
are destructive to the organs in their vicinit}', and 
they increase by occupying the space belonging to 
other structures which have been destroyed by the 
growth of the tumor. These tumors are dangerous 
to the structures in their neighborhood, but do not 
tend to form new deposits of the diseased growth in 
other parts of the body. Such growths are said to be 



PATHOLOGICAL AND MALIGNANT GROWTHS. 227 

locally malignant, but generally benign, that is, they 
destroy the tissues in their vicinity, but they do not 
tend to produce new colonies of the disease in other 
and remote situations of the body. In distinction to 
this, is that great class of pathological growths which, 
at the same time in which they are increasing in size 
in the situation in which they were originally devel- 
oped, also form new plantations of the same disease 
in other and remote parts of the body, so that after 
a time there is not only the original disease at the 
place where it was first noticed, but there is also 
a number of new and separate points in the body 
in which the same disease is to be found, and in 
which it is running its course in the same way as in 
the seat of first development. These growths are 
called malignant, in the broadest and most general 
sense of the term, and belong to the most dangerous 
group of pathological formations. The new colonies 
are produced by the transportation of certain ele- 
ments of the disease, by means of the current 
of the blood or by other channels, to distant 
parts of the body, where they become seated, and 
begin to grow, and reproduce the original disease in 
the new location. This process of new production is 
called " metastasis," and these new centres of disease 
are called "metastatic growths." Such pathological 
growths are always of an extreme degree of malig- 
nancy, and are the most frequently fatal of all the 
new formations which are observed in the human 
body. These growths are, by many able men, grouped 
into one general category, in accordance with their 
clinical characteristics, as belonging to the group of 



228 DENTAL PATHOLOGY. 

Cancer; but this name is not a desirable appellation 
for any class of new formations, from the fact that the 
tumors may be of different histological character and 
of different physical properties, and yet be malignant. 
It is desirable in the nomenclature of pathological 
growths to call them by a name which shall convey 
an idea of the histological composition of the growth ; 
rather than by a name which is common to many 
varieties of pathological formation, and, therefore, 
cannot convey any definite idea of the structure of a 
tumor in any given case. 



CLASSIFICATION OF GROWTHS. 229 



CHAPTER XXVIII. 

CLASSIFICATION OF PATHOLOGICAL GROWTHS. 

The first and most important step in the investiga- 
tion of a pathological growth is to determine the 
tissue of which it is composed, that is, to decide 
whether it arises from the normal tissues of the part, 
and is only an inordinate development of the normal 
structures to be found in that region; or if it is 
composed of some new and unexpected structure, not 
belonging to that part, or, indeed, often not belong- 
ing to any part of the body. The next point is to 
establish what the structure of the growth really is. 
To investigate how it is formed, if it is vascular, if it 
is composed of connective tissue or of epithelium, of 
cartilage, of bone, or of some other tissue. Any or 
all of these histological elements may exist as a patho- 
logical production, when developed in unusual places 
or in unusual amount, and thus from being a useful 
part of the body they may become the cause of dis- 
ease, or of greater or less disturbance. 

Certain pathological growths are found to consist 
of a tissue different from any found in the adult 
body, and, therefore, unlike any of the tissues of the 
part in which the growth is seated. These new forma- 
tions may be very confusing, but they will generally 
be found to correspond to some of the immature forms 
of the human tissues, or to their derivatives, and thus 
will be ranked with the class of growths to which 



230 DENTAL PATHOLOGY. 

they belong. It is well known that the tissues of the 
adult human body are developed from a substance 
vastly different, which in the early days of intra- 
uterine or embryonic life constitutes the whole of the 
body of the embryo. These primary structures are 
replaced by the organs and tissues of a later period, 
and at birth or soon after, there is none of the embry- 
onic tissue to be found in the body, or only limited 
and detached portions in the interior of the long 
bones, or in a few other similar situations. The 
transitory embryonic material, called embryonic con- 
nective tissue, is almost, if not wholly, absent from 
the body of the infant at birth. It has nothing to do 
with the finished structures of the body, but seems 
like a formative material of plastic nature, out of 
which the future organs and tissues of the body are 
developed ; and when this is completed the embryonic 
tissue disappears, and is nowhere to be found. 

In certain pathological growths, however, there is a 
reappearance of this material, the body of the tumor 
being found to consist of connective tissue similar to 
that observed during intra-uterine life, but now ap- 
pearing as a heterologous product during adult life 
in the shape of a tumor. This tumor may not be of 
malignant character even if it is composed of ele- 
ments not found in the human body in a state of 
health, but it may be developed as a transitory tissue, 
for the second time, and may again serve as the 
material out of which other tissues are to be devel- 
oped, as is seen in the process of granulation, in 
which a wound or injury is the seat of development 
of a round-celled tissue, such as is not found any- 



CLASSIFICATION OF GROWTHS. 231 

where in the healthy adult body. This now only 
furnishes the means of filling up any loss of tissue, 
for the time being, out of which the various injured 
parts or tissues are repaired or again developed, much 
as the organs and tissues were originally developed 
out of the embryonic connective tissue in the period 
of intra-uterine life. Thus we see the curious phe- 
nomenon, that a tissue exists in the earliest forma- 
tion of the body of the embryo, from which the 
structures of the new beings are constructed; and 
that in cases of injury to the body in after-life, there 
is a reappearance of this formative or embryonic 
material, by the help of which the repairs are carried 
on until the healing of the injury is completed, when 
the granulation, or embryonic tissue again disappears 
and is nowhere to be found in the body. 

The important and particular point in relation to 
embryonic tissue is this : Granulation tissue, or em- 
bryonic connective tissue, is not a permanent tissue. 
It only exists in the body of the embryo as a tran- 
sitory material, from the conversion of which 
another and entirely different material is to be pro- 
duced. If, now, embryonic tissue reappears in the 
adult body, at a time when there is no process of 
repair going on, and if it accumulates in any con- 
siderable amount, it is easily conceivable that it may 
undergo similar changes to those belonging to it in 
its usual and normal conditions. As it is never a 
permanent tissue, but is always changing to other 
and different forms of tissue, so when it appears in 
the form of a pathological growth, it exhibits a ten- 



232 DENTAL PATHOLOGY. 

dency to undergo further changes, either in the way 
of extension of the disease, or more frequently, in 
the rapid decadence of the tissue already formed. 

Thus it is seen that the pathological growths in 
the body may be of various character, and that the 
nature of these growths and their influence upon the 
body at large is due to the circumstances of their 
structure, their location, and, to some extent, depends 
upon the nature of the different textures entering 
into their composition. Their study is to be pursued 
in relation, also, to their clinical behavior; as the sur- 
roundings of a growth make a vast difference in its 
course, and are often the means of determining its 
effect upon the system of the bearer. Prof. Virchow, 
than whom no greater authority in pathology exists 
at the present day, makes the statement that in &11 
cases of histological examination of morbid growths, 
the most careful study of the clinical symptoms 
attending the development and growth of the tumor 
should be made, as the microscopic examination 
alone is not sufficient in most cases to warrant a posi- 
tive opinion. 

In addition to the general varieties of tumors 
enumerated above, there are the numerous forms of 
swelling caused by the retention of some fluid within 
its gland, or the accumulation of some liquid in 
a cavity which should not exist in the healthy body, 
and which thus causes a tumor or swelling in the 
part affected. These tumors are called " cysts," and 
are observed oftener than in any other manner, in 
the case of obstruction of the duct or orifice leading 



CLASSIFICATION OF GROWTHS. 233 

from a gland, the occlusion of which causes the ac- 
cumulation of the secretion within its gland or the 
duct, which then becomes enlarged, and is often so 
enormously dilated as to present only a thin wall 
containing the fluid. The liquid often accumulates 
to a great amount, so that a large swelling occupies 
the site of a small gland. These cystic collections 
present a peculiar phenomenon upon being lightly 
tapped with the finger. They give the sensation of 
fluctuation, which is a peculiar wave-like motion 
beneath the finger, and which belongs only to tumors 
with a fluid content. We may, therefore, by this 
sign determine if the swelling be caused by the 
growth of a solid tumor, or if it be due to a collec- 
tion of fluid in some cavity in the part. These 
cysts are not rare in the mouth, where there are sev- 
eral large glandular structures, the secretion from 
which is often obstructed in its escape, thus causing 
the accumulation of a considerable amount of fluid 
in the glands or in their ducts, and producing a cor- 
responding swelling in the part of the mouth in 
which the gland itself is located, and which intrudes 
to a greater or less degree into the cavity of the 
mouth. 

Prof. Virchow calls this class of tumors " retention- 
cysts," because they originate from the retention of 
the secretion of the glandular bodies contained in 
the part. The obstruction of the duct causes the 
swelling. 

Such tumors are not uncommon in the parotid 
region, from obstruction to the flow of the secretion 



234 DENTAL PATHOLOGY. 

of this gland, and the swelling is situated in the 
region of the gland, just in front of the ear. One of 
the symptoms which may occur in any affection of 
this gland is paralysis of the muscles of the same 
side of the face, due to the pressure of the swelling 
upon the trunk of the facial nerve, which passes 
through the gland on its way to the muscles of the 
face. The presence of paralysis of those muscles of 
the face which are supplied by the facial nerve, 
should at once direct attention to the parotid gland 
as a possible seat for the disturbance of function in 
the nerve, caused by pressure in its passage through 
the gland. 

It will therefore be seen that the various forms of 
pathological growth can only be differentiated one 
from another by attention to a system of investiga- 
tion which shall determine the points of difference 
between the several varieties. Their study, however, 
in regard to their character must be based upon 
observation of their derivation and structure. We 
are thus obliged to look to anatomy, both macroscopic 
and microscopic for the solution of the question as 
to the origin and the formation of these growths, 
and from these results we may draw certain conclu- 
sions as to the character, dangerous or otherwise, of 
the particular growth under consideration. 

The importance of a competent knowledge of the 
histological structures of the tissues of the body at 
once becomes apparent. Inasmuch as the greater 
part of all the pathological formations of the body 
consist only of derangements of the normal struc- 



CLASSIFICATION OP GROWTHS. 235 

tures, it is imperative that the observer should know 
the relations and the general characteristics of the 
normal tissues of the body before a correct opinion 
of the pathological deviations of the tissues can be 
rationally formed. Upon this conception the descrip- 
tion of the pathological growths observed within 
'the domains of dental surgery will be conducted. 



236 DENTAL PATHOLOGY. 



CHAPTER XXIX. 

HYPERTROPHY. 



Prof. Austin Flint has described hypertrophy thus : 
" The term Hypertrophy is applied to enlargement 
of a part from an increase of its normal constituents, 
the structure and arrangement remaining essentially 
the same. In simple hypertrophy there is an increase 
in the size of the anatomical elements, but not in 
their numbers. In hyperplasia the number of these 
elements is augmented." 

The hypertrophies of the mouth and teeth may 
affect any or all of the tissues therein contained, and 
may beof so slight a character as hardly to attract the 
notice of the patient; or they may reach so extensive 
a development as to seriously impair the comfort or 
even to endanger the life of the patient, from inter- 
ference with the processes of mastication and nutri- 
tion. The hard tissues of the roof of the mouth 
are the seat of frequent hypertrophic changes, which 
tna}' be confined to a small area, or may extend over 
the en tin 1 vault of the oral cavity. 

In cases of simple uncomplicated hypertrophy 
there is usually no indication of disease of the tissues. 
There is no ulceration of the mucous membrane, nor 
is the patient a sufferer from pain or distress of any 
kind. There is simply an inordinate increase in the 
bulk of the normal tissues of the part, with the 
encroachment and disturbance of other structures 



HYPERTROPHY. 237 

which such an enlargement of the tissues would of 
necessity cause in a contracted space as is that of the 
mouth. The hypertrophied tissues are supplied with 
blood vessels and nerves, the same as are the normal 
parts about, and the histological elements are all of 
healthy character. 

In the hypertrophjr of the teeth there is often a 
greater deviation from the normal characters of these 
organs than in the hypertrophy of other parts or 
organs. This is due to the fact that the teeth are so 
situated that any disturbance in their original devel- 
opment, or any disarrangement in their growth, is 
the cause of wider divergence in the form and rela- 
tions of the tooth, than is the case in such changes 
in most of the other tissues of the body. The hyper- 
trophies of the teeth are of two general kinds. First, 
that due to the congenital variation of the form of 
the tooth, and which is born with the individual, 
and is at no time the subject of disease or the occa- 
sion of any inconvenience to the individual. This 
form of hypertrophy is like the deformities occasion- 
ally seen in otherwise healthy individuals in whom 
there is an excessive production of tissues or of entire 
parts.* Those patients sometimes are born with an 

* "Hereditary Polydactyly and Anomaly of Denti- 
tion." British Medical Journal, April 14th, 1888. — In the Natur- 
forscherversam railing, recently held in Wiesbaden, Herr Thomas, of 
Freiburg, brought forward a case of the above-named anomaly, 
which derived special interest from the fact that there was also hered- 
itary malformation of the teeth. Polydactyly had existed for several 
generations in the father's family, and similarly dentitional anom- 
alies affected the mother's side. Some of the teeth were always 
wanting, and the primary dentition in many cases persisted for a 



238 DENTAL PATHOLOGY. 

increased number of fingers or of toes, or they may 
have an abnormal development of some part of the 
anatomy of certain organs, in which there is, however, 
no indication of organic disease. Thus, in one of the 
metropolitan hospitals, a patient was received for 
surgical treatment, who presented the curious phe- 
nomenon of six fingers on each hand and six toes on 
each foot. The person was entirely well ; there was 
no sign of any disease in any part of the system ; 
there was only the abnormal increase of the number 
of perfect organs upon each extremity, which were 
removed by surgical means, and the person made a 
perfect recovery. In another patient known to the 
writer, there is on one hand the formation of a per- 
fect thumb in addition to the thumb naturally 
belonging to the hand, so that the patient never could 
wear a glove upon that hand. The patient is per- 
fectly well and strong, the distortion of the hand 
producing no effect upon the condition of the body. 
In the same manner there is occasionally seen in the 
mouth a variation in development from the usual 
forms, due to some cause of congenital character, and 
in no way affecting the health of the patient nor 
interfering with his nutrition. The affection may be 
confined to the roots of the teeth, or of certain of the 

long time. The offspring combined both kinds of irregularity, for 
one child, aged eleven years, exhibited besides Polydactyly, only 
two upper, and no lower incisors. Milk teeth were present and 
there was a corresponding defective development of the jaw. A 
brother had six ringers on one hand and seven on the other, also six 
toes on each foot; one pair of fingers had grown together; all the 
rest, together with the toes, were separate and well formed; the 
condition of the teeth in this case is not stated. 



HYPERTROPHY. 239 

teeth, and is then the cause of changes in their pro- 
portions and outline; the part which protrudes from 
the jaw being more or less misshapen and often 
clubbed, and the root, which is the seat of the hyper- 
trophic change, being frequently much enlarged, and 
sometimes transformed into a rounded and blunted 
extremity in which no similarity to the ordinary 
and natural tooth can be detected. In the most of 
these cases the deformity of the tooth is not discov- 
ered until the tooth is extracted, or until there exists 
some defect in its nutrition, or pressure is produced 
upon other and surrounding structures by which the 
patient is made to suffer acute pain. At times the 
excessive development of the root of the tooth causes 
a high degree of vascularity in the periosteum, and 
this in its turn occasions a sensitive condition in the 
nervous structures of the root of the tooth, which is 
the source of much suffering to the patient and brings 
him to the consulting room of the dentist. Even 
then there may be no indication other than that 
afforded by the study of the complexity of the symp- 
toms to direct attention to hypertrophy of the root 
of the tooth as the cause of the trouble, and usually 
only on removing the tooth is the hypertrophy dis- 
covered. The extraction of hypertrophied teeth is 
often a matter of great difficulty, owing to the fre- 
quent enlargement of the root of the tooth to such 
an extent that the apex is much larger than the neck 
of the tooth, so that the root cannot pass through the 
orifice which incloses the neck and body of the organ. 
In such cases the alveolar process is not infrequently 
more or less injured, and sometimes extensively frac- 



240 DENTAL PATHOLOGY. 

turecl or comminuted. In many cases the body of 
the tooth is broken or crushed in the attempt to 
extract it, and the crown is separated from the 
remainder of the tooth, which is still inclosed in the 
tissues of the jaw. 

The character of the growth which takes place in 
hypertrophy of the root of the tooth is generally a 
new formation of bone, and not the increase of the 
cementum of the root texture. The periosteum of the 
root of the tooth is also the periosteum or endosteum 
of the alveolar process, and is the lining of the cavity 
in the alveolar process, at the same time that it is the 
covering of the root of the tooth. It is a well-known 
fact that the chronic irritation, or a low form of in- 
flammation of the periosteum will result in the pro- 
duction of a new growth of bone beneath or upon 
the membrane. Thus we see how it occurs that the 
enlargement at the apex, or upon the root of the 
tooth in a state of hypertrophy is composed of bone 
tissue, and not of the cementum of which the body 
of the root of the tooth is composed. The parts are 
not usually further diseased, and after extraction of 
the affected tooth the cavity closes quickly and 
kindly, and the patient is none the worse for the en- 
largement. 

The mucous membrane of the alveolar process is 
sometimes the seat of an hypertrophic condition, 
due to a long-standing irritation of the part, from 
disease of the tooth socket, or the effect of accumu- 
lation of filth about the root of the tooth, or from 
other causes. In these cases the membrane is often 
found thickened, it is seen to be elevated, so as to 



HYPEI1TROPHY. 241 

extend to a higher point upon the teeth than usual, 
and is brawny and elastic to the feeling. Occasion- 
ally the hypertrophy may be observed as a velvety 
elevation of the surface of the membrane, which at 
times rises up at the neck of the tooth so as to cover 
more or less of its body, from which it may be 
pressed back, and the tooth be seen inclosed in the 
mass of tissue about it. 

At times the presence of some form of disease may 
occasion hypertrophy of the tissues in its vicinity. 
Thus in the case of cancer, we may see in the neigh- 
borhood of the cancerous disease, an increase in the 
amount of the normal tissues of the part, due to the 
irritation caused by the nearness of the disease. It 
is at times quite difficult to understand the relation 
which exists between the diseased tissues and the 
increased amount of the normal tissues in the im- 
mediate vicinity. 



242 DENTAL PATHOLOGY. 



CHAPTER XXX. 

CARCINOMA. 



Among the forms of tumors which are termed 
" malignant," and which tend to destroy the part in 
which they are situated, and to threaten the entire 
organism, by destructive growth, or by new forma- 
tions in the way of metastases, is one of great im- 
portance, which has received the name of " Carci- 
noma." This form of growth belongs to that class 
to which the name " cancer " has been applied ; under 
which term is also comprehended a variety of other 
forms of pathological growth, the distinguishing 
characteristic of all of which is their malignancy, 
and their tendency to return after removal. 

These growths are of varying origin, some of them 
being derived primarily and exclusively from the 
connective tissue, and consisting of this tissue alone, 
while other forms are derived from the epithelial 
covering of the body, or from some of the internal 
epithelial structures, such as the lining of the ali- 
mentary canal ; or from some of the glandular struc- 
tures of the interior of the body. These last-men- 
tioned growths, the epithelial growths, are grouped 
under one general head, and belong to the class of 
the Carcinomas. In order to understand the origin 
and the construction of this class of tumors, it is 
necessary to call attention to the peculiarities associ- 
ated with the development and increase of epithe- 



CARCINOMA. 243 

Hum, and then to trace the changes which occur in 
a pathological growth composed of this histological 
element. 

If we turn to the structure of the skin, we find 
that the epithelial covering of the body is developed 
from a layer of the dermal textures called the rete 
mucosum, and that the deeper portion of the epithe- 
lium is composed of a single layer of cells of almost 
columnar shape, standing on end, upon the rete 
mucosum above mentioned. This arrangement is 
continued in all portions of the skin, so that the ap- 
pearance of the skin from any part of the body is 
always the same. The lower layer of cells is grad- 
ually lifted from its seat by the development and 
growth of a new layer under them, so that what was 
at one time the lower layer of epithelial cells is after- 
ward found to be removed toward the surface of the 
skin by the growth of new layers of the same tissue 
beneath them. In this way the cells which are 
formed at the deepest part of the epithelial layer are 
gradually raised toward the surface, until they at 
length form the cuticle, and are removed from the 
skin in washing, or by some other means, as dead and 
useless material. The lower row of epithelial cells 
is placed against the connective tissue, for the rete 
mucosum is composed of connective tissue elements, 
and is supplied with arteries, veins and nerves, 
which the epithelium never has. From this source 
the youngest epithelial cells obtain abundant nour- 
ishment, by absorbing the nutritious material in the 
form of serum and albumen which abounds in the 
connective tissue, and which is capable of support- 



244 DENTAL PATHOLOGY. 

ing the vitality of many animal tissues. It is not 
necessary that blood should everywhere circulate 
for the nutrition of the textures of the body. The 
cornea, which forms the transparent membrane cov- 
ering the front of the eye, through which we see, is 
composed of elements which depend for their nutri- 
tion upon the absorption of material from the sur- 
rounding connective tissues, as no blood vessels nat- 
urally exist in the domain of the cornea. In like man- 
ner the epithelial covering of the skin is supported 
by absorption of nutrient material in the shape of 
fluids from the connective tissue immediately below 
the level of the epithelial border, and the epithelium 
then proliferates from this point upward toward the 
surface of the skin. The amount of material which 
is at hand for the support of the epithelium is quite 
largely in excess of the requirements of the lowest 
layer, and is absorbed through the first few layers to 
minister to the support of the cells which have been 
removed from their original seat by the proliferation 
of the new cells at the margin of the rete mucosum. 
For a time, then, the epithelium is still a vitalized 
and living tissue after it has been removed by un- 
derlying cells from the place of its first formation ; 
and it is still composed of large cells with distinct 
nuclei, and with frequently a toothed margin where- 
by it is united to its companion-cells in forming a 
protective covering to the surface of the body. After 
being raised to a certain extent, however, from its 
original location upon the rete mucosum, the epithe- 
lium cells lie at such a distance from their source of 
supply that the amount of nutritive material is not 



CARCINOMA. 245 

sufficient to extend through the intervening mass of 
new-formed epithelium, and to maintain the vitality 
of these older cells; and these cells then begin to 
suffer decay, and after a little more elevation toward 
the surface of the skin, they are seen to be smaller 
than before, and to take on a shriveled appearance, 
and to lose their nuclei, which until this point was 
reached, were distinctly visible. From this time the 
epithelium composing the protecting covering of the 
body is comprised of a mass of dead and dried cells 
of epidermis, which become more and more desic- 
cated as they approach the surface of the. skin, until 
they are "cast off as mere dried particles of cuticle 
such as are combed from the hair or can be scraped 
from the skin of the arm with the flat edge of a 
knife, without injuring the tissues or causing pain. 

It will be perceived that the cells of epidermis, in 
their growth from the lower layer of their develop- 
ment toward the surface of the skin, retain their 
vitality for a certain length of time after they have 
left the boundary of the connective tissue and have 
started on their way to the surface. For a certain 
distance from the level of the connective tissue they 
can still absorb nutriment through the cells which 
have developed below them, are younger than they, 
and have lifted these earlier cells away from the con- 
nective tissue where they were formed, and for a cer- 
tain time lay in contact with the connective tissue. 
At a certain distance, however, from the border of the 
connective tissue the cells of the epithelial layer cease 
to receive sufficient nutritive material to support their 
vitality. The entire supply is used up by the cells 



246 DENTAL PATHOLOGY. 

lying nearer the connective tissue ; and these cells, 
which are daily becoming further and further removed 
from the point of their origin, the rete mucosum, or 
the connective tissue, at length die, from lack of sus- 
tenance, and begin to undergo the changes due to 
their necrosis, to become dried and flattened, to lose 
the nucleus which has before this time characterized 
them, and to form the outer horny or insensitive layer 
of the epidermis, the cuticle. Thus, it will be seen 
that the epithelial cells of the body are dependent on 
other tissues of the body for their nutritive supply, 
and that when they are removed to any great distance 
from their source of nutritive supply by the develop- 
ment of new layers of epithelium beneath them, 
they lose their vitality, and begin to undergo a retro- 
gressive change in the direction of desiccation, and 
are at last cast off from the surface of the skin as a 
part of the worn-out cuticle. For a certain distance, 
epithelium is a living, vitalized tissue; beyond this 
limit it is a dead and useless mass of debris, which 
is finally cast off from the body. 

Now, we have observed that the epithelial tissues 
are, without exception, situated upon the external 
surfaces of the bod}^; that they are not contained 
within the serous or other closed cavities of the 
organism, but without exception are so situated that 
they communicate with the outside of the body, and 
with the air. When they are cast off, they are always 
thrown off upon the surface of the body or into pas- 
sages or channels which communicate with the out- 
side of the body. They are never retained within 
the cavities of the body or limbs, or in any other 



CARCINOMA. 247 

locations, under any normal or usual conditions. If 
this should occur, we should have an accumulation 
of cast-off epithelium contained in some portion of 
the body where it could only act as a useless and 
disordered incumbrance to the organism. This really 
takes place in the formation of one of the retention 
tumors, called Atheroma, or Wen, in which the epi- 
thelial formations of certain glandular structures are 
retained in the cavity of the gland, from the occlu- 
sion of its orifice ; and there is at length formed a 
mass of greater or smaller size, composed entirely of 
the accumulated epithelium so retained, or of the 
substances produced by its decomposition, with occa- 
sional additions of hair, or other epidermoidal struc- 
tures. It is as if a portion of the skin were turned 
into the flesh, and were closed in on all sides, so that 
it formed a hollow ball, and when the epidermis is 
cast off in such a case, it is simply cast into the 
middle of the ball, and is there retained, because no 
orifice to the surface of the skin exists by which it 
may reach the surface. The entire contents of the 
tumor is dead epithelium or its decomposed remains. 
If, now, we suppose that a portion of the epithelium 
of the surface of the body should, for some unknown 
reason, start to develop downward into the connective 
tissue, instead of upward toward the surface of the 
body, we should have essentially the same result 
which we have described in respect to the wen. We 
should find a mass of epithelial development where 
no epithelium should normally exist. Connective 
tissue and epithelium do not mix. Where connective 






248 DENTAL PATHOLOGY. 

tissue exists, epithelium is not found, unless it simply 
comes up to the connective tissue, and is attached to 
it as a boundary, but it does not enter into the com- 
position of the connective tissue. The downward 
development of epithelium, therefore, must cause the 
displacement of a certain amount of the connective 
tissue, to allow space for its advancement. The epi- 
thelial prolongation, therefore, resembles a finger 
introduced into a mass of dough ; and has almost the 
same effect as would a foreign body introduced into 
the subcutaneous tissues of the part. There is a cer- 
tain amount of inflammato^ reaction at the seat of 
the epithelial invasion, but the growth goes on ; and 
larger and larger masses of epithelium are formed in 
the connective tissue ; — in a location, therefore, in 
which epithelium does not belong, and where it is 
never found in a state of health. It is the invasion 
of the connective tissue by the unnatural prolonga- 
tion of epithelial processes into it, which constitutes 
the histological element of one of the largest classes 
of that variety of disease called Cancer ; and it is the 
sole anatomical cause for all the jDhenomena con- 
nected with the growth of Carcinoma in any of its 
forms. If we examine any form of carcinoma, 
located in any part of the body, at an early stage 
of its development and under favorable conditions, 
we shall find that it takes its origin at the point of 
its first appearance, from the development and growth 
of epithelial tissues in a place and under conditions 
under which epithelium is not normally developed 
or found. The intrusion of epithelium into the 



CARCINOMA. 249 

domain of the connective tissue is the histological 
cause of carcinoma; and the origin of this variety 
of cancerous disease is to be found in a disordered 
growth, and a wrong direction of the epithelial for- 
mations of the body. 

There are several different varieties of epithelium, 
and there are correspondingly varying forms of 
carcinoma, but the disease is the same in all essen- 
tial characters, and the progress and result are the 
same, except in so far as these may be influenced by 
the accidental circumstances attending the develop- 
ment of the disease in certain regions of the body, 
or the variations in blood supply, or other sub- 
ordinate circumstances. 

It is not easy to obtain the typical picture of de- 
veloping carcinoma, for the reason that at this time 
the disease is so slight in character, and so small in 
extent, that the patient is unable to think that it is 
the beginning of a serious and probably a fatal 
malady; and, also, for the reason that the early 
development of the disease is often hidden in cavities, 
or so situated that it escapes the attention of the 
patient until the pain or other symptoms attending 
its further development are sufficient to call the 
disease to the patient's notice. Thus, in a case 
recently seen by the writer, which ended fatally in 
a short time, the carcinomatous disease commenced 
in the deepest part of the navel, and the patient, a 
lady, did not seek medical advice until the pain and 
weakness caused by the disease had so reduced the 
strength that all hope of any alleviation of the dis- 
ease was at once abandoned. 



250 DENTAL PATHOLOGY. 

Wherever the carcinomatous disease is located, 
and under all the conditions which are observed in 
its course, the main element is the encroachment 
of the epithelial tissue into territories in which, 
normally, no epithelium is developed, and where it 
does not belong. The manner of growth is by 
prolongation of masses of the epithelium in the 
shape of finger-like processes into the surrounding 
structures, which it displaces, and which are so 
crowded by it that they are removed by absorption, 
or are destroyed by the unaccustomed pressure of 
the new growth. In this way the connective tissue 
is removed, the muscles are caused to disappear, the 
fat is absorbed, and in the place of all these struc- 
tures is seen the development of masses of epithelium, 
of the kind natural to the part in which the carcino- 
matous disease was first developed. After a time, 
the blood vessels of the part may become involved 
in the diseased tissue, as the new growth increases 
around them, until it quite envelops them in its own 
tissue. It is then possible that certain of the vessels, 
both of arterial and of venous character, may be 
penetrated by the cancerous growth, and that hemor- 
rhage may ensue, or that particles of the disease may 
enter the current of the blood, and may be carried 
to other and distant parts of the body, where, then, 
they may form the starting-point of a new deposit 
of the original disease. Here, again, the epithelial 
cells are of the same kind as those observed in the 
original seat of the disease, and they increase in the 
new location, forming masses of disease similar in all 
respects to those noticed at the point of origin of the 



CAECINOMA. 251 

carcinoma, when it first appeared in the patient. 
The deposit thus formed is called a metastasis, and is 
a secondary formation, of the same character in all 
essential respects as the original disease. Other 
metastases usually occur if the patient survives long 
enough after the disease has become thoroughly 
developed. 






252 DENTAL PATHOLOGY. 



CHAPTER XXXI. 

ULCERATION IN CAECINOMA. 

The destruction of the tissues which follows the 
invasion of carcinoma is due, as has been shown, to 
the enormous development of epithelium in loca- 
tions in which this tissue does not naturally belong, 
and under circumstances in which no epithelial 
tissue is naturally produced. The next stage, that 
of ulceration of the carcinomatous mass, is produced, 
however, by conditions affecting the epithelium 
alone. It is well known that all cancerous affections 
are characterized by a tendency to ulcerate, and thus 
acid the dangers of an open suppurating wound to 
those attending the formation of a malignant tumor. 
It has been shown on a previous page that the 
epithelial cells which are produced upon the rete 
mucosum undergo a process of gradual starvation 
from lack of nutritive material as they are pushed 
further and further away from the surface upon which 
they were developed, until they at length are cast 
off from the cuticle as dead and withered particles 
of the desiccated epidermis. 

For a certain distance the epithelium is a vitalized 
and living tissue ; after this, the epithelial cells are 
simply so much dead material, which nature grad- 
ually forces to the surface, until they are thrown off 
with other debris of the system. Thus we see that 
the line of the advancement of the epithelial growth 



ULCERATION IN CARCINOMA. 253 

is followed at a regular distance behind it, by a line 
of necrosis, represented by the death of the epithe- 
lial cells which have been formed ; and that this 
necrosis of the cells must follow every advance of 
the epithelium into new domains, and thus carry 
the ulcerative process into every part into which the 
cancerous process has entered. If the cancerous 
disease has attacked the lip or face, it gradually 
spreads, until the entire face is affected, and the 
necrosis of the cancerous growth causes great loss of 
substance, until the entire skeleton of the face may 
be exposed, the tongue may be destroyed, the nose 
may be lost, and the patient may at length suffer a 
tedious and agonizing death from gradual starvation ; 
due to inability to take food, owing to the destruction 
of the organs of mastication and deglutition. 

If the carcinomatous mass is allowed to go on un- 
disturbed, it is sure to communicate with the lym- 
phatic channels which are everywhere distributed 
through the tissues, and the result of this is seen in 
the swelling and hardness of the glands located upon 
these lymphatic vessels which are nearest to the seat 
of the original disease. These glands are at first 
only indurated or swollen from the irritation of the 
cancerous mass which is situated in their vicinity ; 
but soon they are found to contain the real elements 
of the carcinomatous disease in the shape of deposits, 
or new depots of epithelium in organs in which nor- 
mally no epithelium is found, and into which it has 
been transported by means of the lymphatic vessels, 
thus forming a metastasis of the disease from its 



254 DENTAL PATHOLOGY. 

original seat to the nearest lymphatic glands. After a 
time the disease breaks through these glands, which 
act like a temporary barrier to stop the advance 
of the pathological process. The cancerous disease 
then passes into the larger lymphatic channels of the 
body ; or it enters the veins or arteries, and is then 
transported by the current of the blood into any 
part of the body where it may chance to be carried, 
and there produces new colonies of the same disease, 
called secondary metastases. The disease has now 
arrived at such a degree of dissemination that the 
chance of the patient surviving its ravages or of re- 
ceiving any benefit from treatment are extremely 
small, because in all the locations in which it has 
appeared, the same process of exaggerated epithelial 
development is carried on, and the same consequence 
of subsequent necrosis of the epithelial new forma- 
tions takes place at a point just behind the line of 
advance of the disease. It frequently happens that 
the internal organs of the body are the seat of the 
secondary metastases of cancer, and of these the liver 
is most often affected. 

When the disease has reached this degree of devel- 
opment, and has thus appeared in the internal por- 
tions of the body, and has invaded the visceral 
organs, there is generally observed a new train of 
symptoms, due to the poisoning of the system of the 
patient by the cancerous infection, or virus ; or due to 
the presence of so many centres of malignant disease 
in the important organs of the patient's body. The 
color of the skin becomes yellow, the skin is dried 



ULCERATION IN CARCINOMA. 255 

and shriveled, there is loss of strength, and extreme 
emaciation, with increasing weakness, and the diges- 
tion as well as other functions of the body become 
enfeebled and unable to fulfill their office in the 
nourishment of the patient. This condition is called 
" marasmus," and is one of the final results of the 
general invasion of the body by any specific form of 
grave disease, and is threatening, more from the fact 
that it is an indication of profound exhaustion of the 
powers of the body, than from the effects of any one 
of the symptoms which go to make up its presence. 

The life of the patient is now usually of short du- 
ration, and death most frequently occurs from sheer 
exhaustion, or from starvation, or from the failure of 
the system to assimilate the food taken, which is only 
another form of starvation. 

There may be hemorrhage from some blood vessel 
which has been opened, and this may quickly ter- 
minate the life of the patient by sudden collapse. 
Occasionally the disease is observed to make a 
metastasis to the brain, and the later period of the 
patient's life may then be obscured by the signs of a 
grave disturbance of the cerebral functions, or by 
entire unconsciousness. 

We see, therefore, that the histological character of 
carcinoma, one of the most uniformly malignant 
and universally fatal diseases we know, is comprised 
in one of the most abundant and well-known tissues 
of the body ; and that this tissue is only the cause of 
the disease when it is found growing under unusual 
and abnormal conditions. The clinical symptoms 



256 DENTAL PATHOLOGY. 

attending this form of cancer are due to the presence 
of epithelium in locations where it does not belong, 
and also to the fact that the epithelial tissue can only 
retain its vitality for a certain distance from the basis 
of connective tissue where it is formed ; and that the 
necrosis of the epithelium when it can no longer 
obtain sufficient nourishment, is the cause of the 
ulceration and the frightful loss of tissue which 
accompanies the ravages of this dreaded disease. 

From this it will be seen that a pathological 
growth, even of malignant character, may not differ in 
any way from the ordinary constituents of the human 
body, the simple variation of location and arrange- 
ments of the cellular elements, or their relations with 
the surrounding tissues being often quite sufficient to 
induce the features of malignancy into the formation 
of an otherwise ordinary tumor. Not all epithelium 
will form a malignant growth when it is placed in 
relation with the connective tissues, and it is impos- 
sible to originate the disease in animals; though 
cancer is often known to follow certain forms of pro- 
longed irritation of the part affected, in the human 
subject. There seems to be a hereditary or an 
acquired tendency to the disease ; a congenital pre- 
disposition to cancer, such as affected the members 
of the family of Napoleon I, which leads to the 
formation of cancer in their descendants. In a case 
known to the writer and reported by him in Graefe's 
Archiv, carcinoma was developed in the conjunctiva 
of a clergyman seventy -two years old, whose mother 
had died of cancer located in another part of the 



ULCERATION IN CABCINOMA. 257 

body many years before. The reason why, or the 
manner in which, the tendency to certain diseases is 
thus transmitted from one generation to another is 
not known ; nor is the specific quality of the infective 
material, which can retain its fatal power through so 
many years and then develop its malignant char- 
acter, at all understood. 



258 DENTAL PATHOLOGY. 



CHAPTER XXXII. 

MALIGNANT GEOWTHS, CONTINUED. SARCOMA. 

The other great class of malignant growths which 
is included under the general name of Cancer, is 
produced in another manner from that just described 
and is developed from a different tissue. These 
growths are developed from the connective tissue, 
and consist of normal or degenerated connective 
tissue. They are located in any part of the body, 
are not necessarily in any constant relation to any 
special organ or structure, such as we have seen 
that carcinoma always exhibits. Unlike the carci- 
noma, the connective tissue growths do not necessa- 
rily undergo degenerative or retrogressive changes. 
This branch of the malignant growths of the body 
is called " Sarcoma," from its resemblance in gross 
features to the flesh of an animal when recently cut. 
They are sometimes called " flesh tumors " on this 
account, by the older writers upon morbid growths. 

Being produced from the connective tissue, the 
tumors belonging to the sarcomatous group are de- 
veloped beneath the skin, and not upon it or in its 
texture. The pathological growth may be observed 
only as an increase in the connective tissues of the 
region, without definite boundaries or sharp outline, 
and may not differ in any gross characters from the 
tissues about the spot where it is located. The in- 
crease in the size of the tumor, the fact that it dis- 



SARCOMA. 259 

places the normal tissues and organs by the infiltra- 
tion of their textures with the elements of its own 
histological structure, and thereby causes the disap- 
pearance of important parts or organs, from the 
encroachments of the morbid growth, gives to -this 
class of tumors a degree of importance which they 
would not otherwise possess. The loss of substance 
from these tumors is due in part to the fact that the 
large increase in the element of connective tissue, 
not infrequently is followed by the softening of the 
textures of the new tissue. This is thus rendered 
more easily liable to injury or disease, and therefore 
much more likely to take on the appearance of 
degenerative disease of the textures of the tumor 
than is observed in cases of pure hypertrophy of any 
of the subcutaneous tissues. Simple hypertrophy, 
even when the increase in the size of the part is so 
great as to cause distortion and inconvenience to the 
patient, is not often followed by the degeneration of 
the tissues thus formed. In the sarcomatous growths 
there is, however, a tendency to change in the his- 
tological elements of the growth, and the diseased 
tissue also possesses the additional peculiarity of 
easily being transported to other parts of the body, 
where it forms the nidus for the development of the 
malignant disease at this new location. 

The chief difference in the location of the Sarco- 
mata in distinction from the Carcinomata is found 
in the character of the tissues from which each of 
these two varieties of morbid growth is formed. 
The carcinomata, arising in all cases from epithelium, 
is first developed upon some surface or in some struc- 



260 DENTAL PATHOLOGY. 

hire in which epithelial tissue is present, either as a 
normal constituent of the part or as an accidental con- 
dition. As has been shown, epithelium is the consti- 
tuting element, the invading factor, the essential 
substance of the carcinomatous disease. In all its 
advances, epithelium is the one indispensable element. 
In the sarcomata, on the contrary, the disease arises 
from the connective tissue, and can take its origin in 
any part of the body in which this tissue is found. 
When we realize that connective tissue is the one 
universal tissue, that in any and all parts of the 
body it is the supporting and connecting substance 
between other and various organs and tissues, and is 
associated with every structure of the entire anat- 
omy, we can at once perceive that the growths aris- 
ing from this tissue may be found in all portions of 
the body, and in relations with all the textures which 
are located beneath the skin and mucous membranes. 
Such a growth arising from the fibrous textures of 
an aponeurosis would be called a fibro-sarcoma ; 
when arising from the structure of a lymphatic 
gland, it might be called an adeno-sarcoma ; when 
originating from the tissues of bone (from the con- 
nective tissue contained in the canaliculi or other 
textures of bone), it would be designated an osteo- 
sarcoma; and when it arises from the delicate reticu- 
lated connective tissue found in the internal struc- 
tures of the nervous system, it receives the title of 
glio-sarcoma. Thus it will be seen that the connec- 
tive tissue growths, though arising from the same 
substance as a basis, are variable, according to the 
form which the basis takes in the different parts of 



SARCOMA. 261 

the body. Not all the varieties of sarcoma are ma- 
lignant, in fact, some of them are distinctly non- 
malignant, but the origin of the growth is at all 
times the same; the only exception in character 
being found in the kind of connective tissue which 
affords origin to the growth. The degree of malig- 
nancy is found to be associated chiefly with the size 
of the cellular elements of which the growth is com- 
posed, and the finer the elements, and particularly 
if there is a tendency to present a variety of cellular 
forms in the same growth, the greater is the degree 
of malignancy of the tumor. The change in histo- 
logical structure is always in the direction of less 
stable and more feeble forms of tissue, and these 
present a greater liability to break down and to 
undergo gangrene, or in other ways to become 
necrosed ; and thus to inaugurate the destruction of 
the tissue, and to produce an open ulceration at the 
seat of the tumor. When the loss of substance has 
thus once occurred in a sarcomatous growth, there is 
little probability of spontaneous healing of the tissue 
taking place, but the course is usually in the direc- 
tion of a progressive increase of the ulceration, a 
greater loss of tissue, and the rapid exhaustion of the 
strength of the patient from the loss of fluids, and 
the extension of an acute gangrenous process in the 
vicinity of the growth. 

One of the forms of Sarcoma is not infrequently 
met with in the structures of the jaw. It most com- 
monly takes its rise to one or the other side of the 
symphysis, and usually in the region of the canine 
or bicuspid teeth. The form in which it is often 



262 DENTAL PATHOLOGY. 

observed is that of an oblong, more or less raised 
swelling and thickening of the alveolar process of the 
lower maxilla, with a softening of the bony structure 
and a loosening of the contained teeth, which are 
often found out of their normal relations with the 
rest of the denture and frequently placed at an angle 
with their proper direction. Not infrequently one or 
more of the teeth have become loosened to such an 
extent, by the softening of the alveolar process, that 
they have been extruded from the jaw, or have 
become so troublesome that they have been extracted 
by the dentist for the convenience of the patient. If 
a jaw thus affected be made the subject of examina- 
tion, it will be found that an instrument applied to 
the alveolar process encounters much less resistance 
than is natural in the part, and by moderate pres- 
sure may sometimes be driven into the interior of 
the maxillary bone. The outline of the jaw is usu- 
ally much distorted, and the line of the denture is 
generally destroyed. There is more or less invasion 
of the floor or roof of the mouth, and the tongue is 
crowded to the back of the oral cavity, or to the side 
of the mouth opposite to that upon which the patho- 
logical growth is situated. The mucous membrane 
may be intact over the entire surface of the growth, 
and there may be no appearance of disease in the 
relations or secretions of the salivary glands. If the 
growth be carefully observed, it will be noticed that 
it rapidly increases in size, and that the consistence 
of the growth itself, and that of the surrounding- 
parts, is changed, so that an increased softening of 
the tissues in and about the tumor is observable. 



SAECOMA. 263 

With the loss or extraction of the teeth included in 
the area occupied by the tumor is often associated 
the first appearance of the destructive or malignant 
character of the pathological growth. The cavity 
occupied by the tooth or teeth is often the seat of the 
first appearance of the ulceration or necrosis of the 
new growth, and exhibits the first positive indications 
of its dangerous character. If the disease be removed 
by section of the maxillary bone on each side of the 
area occupied by the disease, it will be found that the 
whole interior of the bony tissue has been invaded 
by the sarcomatous development, and that the sub- 
stance of the bone has been in great part destroyed, 
and replaced by the tissue of the tumor. The peri- 
osteum is sometimes apparently intact upon the out- 
side of the bone, and frequently there is seen a forma- 
tion of new bone as the result of the irritation of the 
periosteum from the proximity of the diseased pro- 
cess, so that oftentimes strange and fantastic pictures 
of bony development are thus produced. If sarcoma 
in most of its forms is allowed to advance upon its 
course without the employment of preventive or 
restrictive treatment, we observe a metastasis of its 
elements similar to that noticed in speaking of the 
Carcinomata. After a time, which is variable in dif- 
ferent cases, we observe in the regions about the seat 
of the original tumor, or in remote parts of the body, 
the appearance of nodules, which increase in size, 
and prove to be composed of the same elements as is 
the original growth, and to possess the same tendency 
toward the surrounding tissues, and to present the 
same characters in respect to invasion of the terri- 



264 DENTAL PATHOLOGY. 

tory about them, and the same liability to undergo 
retrogressive changes, and to thus cause ulceration 
in the regions in which they are situated. These 
metastases are not always to be found upon the 
surface of the body, but may take place in the 
internal organs, or may be found in the brain ; in 
which locations they may cause the signs of soften- 
ing of the brain, or may cause some of the appear- 
ances of mental disease, or may produce paralysis. 
At times the development of sarcoma is observed in 
the tongue, or in some of the soft tissues about the 
floor of the mouth, or in relation with the glands of 
the part, particularly the parotid gland. These dis- 
eases are all of serious nature, and should be early 
subjected to careful and complete extermination by 
surgical means ; as the smallest portion left behind 
in an operation for removal of a sarcomatous growth 
is almost sure to be the means of reproducing the 
entire disease, and often in an aggravated form. A 
relapse of a tumor, or a metastasis, in other words, is 
almost always more serious in its influence upon the 
system than was the original disease. There is a 
time in almost all forms of tumors during which 
they seem to be possessed only of a local character, 
and during which time they may be fully and com- 
pletely eradicated by proper local treatment, the 
object of which should be to remove every particle 
of diseased tissue and to take out with it a margin 
of the sound and uninfected flesh on all sides of the 
tumor. In this way it is often possible to remove all 
traces of a growth, which, if left undisturbed, or if 
injudiciously treated, would certainly become dis- 



SARCOMA. 265 

seminated through the system and would bring 
about the death of the patient. The appearance of a 
new growth in any part of the body, but especially 
in the soft structures, is always a suspicious circum- 
stance, and the rapid increase in size of such a growth 
is indicative of malignancy in its nature. It is desir- 
able to form an opinion of the nature of a patho- 
logical growth at as early a period as possible, so 
that treatment for its removal may be carried out 
before it has reached a degree of dissemination in 
the body of the individual, or has invaded parts 
of such a character, that the surgeon cannot safely 
follow it for its complete extermination. 

When sarcomatous growths are observed in the 
upper jaw, they are most frequently located in, or are 
adjacent to the cavity of the antrum of Highmore, 
and are usually accompanied by bulging of that 
portion of the alveolar process which is situated over 
this cavity. Or they may be seated upon the base of 
the sphenoid bone, or spring from some other point 
upon the base of the skull, and by their growth may 
project into and fill out the nasal space, and at length 
produce the appearances of tumor of the superior 
maxillary bone. 

Such growths are usually possessed of a greater 
degree of malignancy than are the sarcomata of the 
lower jaw, owing, in part at least, to the greater vas- 
cularity of the tissues of the upper maxilla. The 
tumor may develop rapidly and fill the entire nasal 
fossa of one or the other side, and portions may 
extend into the anterior and posterior openings, so 
as to entirely occlude the passage. The growth of 



260 DENTAL PATHOLOGY. 

the tumor may cause the absorption of the turbinated 
bones; it may press the nasal septum to the opposite 
side, and it may occasionally encroach upon the 
nasal fossa opposite to that in which it was first devel- 
oped. When any such massive development of the 
pathological growth has been reached, it is usually 
found that the palate process of the superior maxil- 
lary bone is more or less affected, and at times there 
is destruction of the bony tissue, and sometimes even 
a perforation of the roof of the mouth by the malig- 
nant growth. When the origin of the tumor is at the 
base of the skull, there is a greater liability that it 
will appear on both sides of the nasal septum, and 
thus encroach upon the functions of both sides of the 
nose, as well as affect both sides of the maxillary 
bone in its further development. 

Certain connective-tissue growths of the upper jaw 
are related to the parotid gland, and from this point 
of origin extend into the neighboring parts of the 
upper jaw. These growths are always unilateral, are 
accompanied by swelling in the region of the gland 
itself, and are often associated with paralysis of the 
muscles of the side of the face upon which the tumor 
is located. The occurrence of facial paralysis should 
always lead to a careful examination of the parotid 
region ; for the facial nerve in a portion of its course 
passes through a part of the gland, and any indurative 
affection of this structure, or any increase in its tex- 
tures, may evidence itself by the suspension of the 
function of this nerve or of its branches, from pres- 
sure upon its trunk in this part of its course. Often- 
times the beginnings of a growth of undoubted malig- 



SARCOMA. 267 

nant character are from small areas of connective 
tissue in the glands of lymphatic or other character. 
The primary enlargement of these textures may thus 
sometimes be productive of indications in the direc- 
tion of morbid formations, which have the highest 
importance. 

The tumors belonging to the structure of the tooth 
itself are not numerous, and belong to a compara- 
tively restricted class of pathological growths. Among 
•the true tumors of the teeth are to be reckoned the 
frequent cases of enlargement of the apical extremity 
of the tooth, extending to a greater or less distance 
toward the body or crown of the tooth. These 
enlargements, though frequently caused by a long- 
continued and slowly-advancing irritation of the 
connective-tissue textures of the tooth, are not gen- 
erally the cause of any apprehension in the direction 
of malignancy. They are usually observed only 
when the tooth has been removed, either on account 
of the pain sometimes accompanying the irritative 
process above spoken of, or they may, by their size 
and position, cause the displacement of the tooth, 
from the lifting of its body by the growth of the 
tumor at its root. The bony growths at the roots of 
the teeth are not usually accompanied by any ten- 
dency to extend beyond the situation first occupied 
by them ; they do not exhibit a disposition to form 
metastases, and are therefore in all essential respects 
of benign character. The periosteum about them 
may be a trifle thickened in some cases, much as the 
skin becomes thickened at the location of some old 
injury, but the condition of both the hard and the 



268 DENTAL PATHOLOGY. 

soft tissues about the seat of the enlargement is not 
usually affected by the proximity of the morbid 
growth. 

Among the pathological growths of true dental 
nature must be classed those rare developments of 
pathological character which are composed of true 
dental tissues, and not of bone. To a certain degree 
the development of the dental textures into abnormal 
forms is not an infrequent occurrence, as is noticed 
in the formation of masses of so-called "secondary 
dentine," in the teeth of the aged, or in certain teeth 
which have been much subjected to wear. The 
development of an accessory portion of the dentine 
is then to be regarded as a conservative process on 
the part of the system, for the better preservation of 
the textures of the teeth, when these have been dete- 
riorated or reduced by excessive use, or by the 
changes incident to advancing life. The extent to 
which this process may be carried on in certain cases 
is truly remarkable, and teeth are at times seen in 
which a large amount of a useful tooth is made up 
of the deposit of new dentine, forming a serviceable 
substitute for the portion of the tooth which has been 
lost by attrition, or has in some other way suffered 
gradual destruction. In such teeth the cavity of the 
interior of the tooth, the pulp canal, is also often 
intruded upon by the process of secondary formation 
of dentine, and we see the new material located in 
the interior of the pulp canal as irregular masses of 
dentine, or sometimes as small isolated nodules, which 
are often called "pulp stones." Such teeth are not 
usually sensitive to pressure ; they are often quite 



SARCOMA. ' 269 

anaesthetic, from the absorption of the sensitive por- 
tions of the pulp, so that they appear much like those 
teeth in which the nervous pulp, the sensitive por- 
tion, has been removed by surgical means. This 
pathological process has a great similarity to a pre- 
servative function, and might be called constructive, 
in distinction to destructive pathology. 

In rare instances we may observe the formation of 
true tumors composed of the same kind of tissue as 
that forming the body of the tooth, that is, of true 
dentine, and presenting all the characteristics of this 
tissue, and not those of ordinary bone. The develop- 
ment of large masses of dentine is not frequent, and 
the specimens of this disease are rare in the extreme. 
For a very interesting account of a tumor of this 
character, situated at the side of a tooth, and inclosed 
within the alveolar process, see London Lancet, Janu- 
ary 14th, 1888, by Mr. Jordan Lloyd, f. r. c. s., which 
is called in the report a " composite odontome." The 
growth in this case was observed to possess a radiat- 
ing structure, with regular composition corresponding 
in histological arrangement and general character to 
the ordinary dentine of normal tooth structure. The 
specimen has been preserved, and is figured in the 
article above alluded to. 

In certain cases there is observed a fusion of parts 
or the entire mass of neighboring teeth, forming a 
large and irregular collection of dental tissues, some- 
times composed of mingled portions of dentine and 
enamel, confused with one another, and forming a 
most perplexing study. These irregular growths are 
most frequently the result of malformation during the 

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272 DENTAL PATHOLOGY. 

developmental period of the denture, or fusion of one 
or more adjacent teeth, and are doubtless associated 
with the malposition of the tooth germs, or with 
accident attending their growth. That these are the 
chief causative elements is indicated, though not 
proved, by the fact that these malformations are not 
observed in the primary denture. It would seem 
that the period of development of the second denture 
is the time of formation of these curious dental ir- 
regularities. 

Another curious pathological production of the 
dental tissues is observed in certain of the formations 
which are observed in the composition of some of 
the tumors of the ovaries in women. These tumors 
are often quite large, and the operation for their 
removal constitutes one of the forms of laparotomy. 
In certain of these tumors, called Dermoid Cysts, there 
are sometimes found portions of fcetal bones of 
irregular character, hair, sometimes in great abund- 
ance, and strangest and most unaccountable of all, 
there are often found well-developed teeth, or dwarfed 
or misshapen masses of dental tissues, containing all 
the histological elements of the normal structure of 
the human tooth. These tumors are not the result 
of conception or of impregnation, but are the abnor- 
mal product of some diseased process in the body of 
the patient, which has as its result the formation of 
portions of the human organism in unusual loca- 
tions and in strange surroundings. 



ENCHONDROMA. 273 

ENCHONDROMA. 

Several varieties of cartilaginous growths are ob- 
served in the region of the mouth, but these are not 
common, and are usually of benign character when 
they exist, and, moreover, they are usually or at least 
frequently of congenital origin, so that they are not 
considered to be of great importance to the well- 
being of the individual. This class of growth does 
not tend to make metastases, nor to seriously inter- 
fere with the health, and is usually made the subject 
of operation more for cosmetic reasons than from any 
other cause. The substance of the tumor is always 
one of the varieties of cartilage, and the class of 
growths is for that reason denominated "enchon- 
droma." They sometimes increase in size to a degree 
to produce deformity of the face, but do not gener- 
ally degenerate into other forms of tissue, nor pro- 
duce ulceration or any other serious organic result. 



INDEX 



PAGE 

Abnormal direction of teeth 124 

Abscess, alveolar 161 

"cold" 218 

from chronic inflammation. 217 

idiopathic 151 

Absorbent organ of primary teeth.. 110 

Absorption in deciduous teeth 39 

of callus 47 

of roots of deciduous teeth.... 36 

versus caries 42 

Acid eructations in the mouth 75 

saliva in diabetes mellitus... 30 



infancy 30 

Actinomycosis hominum 226 

Action of acids in caries 167 

upon teeth 75 

Allport on caries 168 

Alveolar abscess 161 

space for secondary teeth.... 112 
Analysis of pathological condi- 
tions 64 

Anomalies in size of teeth 121 

Antrum of Highmore 15 

perforation of by root of 

tooth 59 

place for puncture of 16 

surfaces of 16 

Articulation of superior maxilla.. 17 

Atheroma 247 

Atrophy from inflammation 216 

Atropine 31 

Axial rotation of incisors 127 

Bacteria and suppuration 82 

in caries 171 

in the mouth 78 

in necrosis 83 

migration of 82 

Bacterium of decomposition or 

putrefaction 81 

Bone, consistency of in sarcoma ... 262 

in new locations 154 

necrosis of 157 

rachitic, composition of. 134 

regeneration of 65 

Bones of face 14 

Brain, invasion of by carcinoma. .. . 255 

Bullet in tusk of elephant 152 

Calabar bean 31 

Calcareous pus 218 



PAGE 

Callus in fracture of bones 47 

Cancerous growths 222 

growths in the mouth 64 

Canine eminence 16 

fossa... 16 

Carcinoma 242 

of conjunctiva 256 

Caries 159 

causes of 167 

of teeth 141 

origin of. 164 

vs. absorption 42 

Carotid artery 27 

Case of defective denture 117 

of retarded development in 

jaw 95 

Cat-teeth 72 

Causes of inflammation of tooth... 138 

Cement 33 

Central caries 160 

Character of pathological growths 223 

Cheesy pus 218 

Chemical action, effect of on the 

teeth 63 

changes in caries 168 

Children, malnutrition of 68 

Classification of pathological 

growths 229 

Cleft, origin of 87 

Chronic inflammation of teeth.... 150 
Cohnheim, Prof., on inflammation 194 

Condyle, motions of 20 

Congenital tumors 223 

Conjunctiva, carcinoma of 256 

Connective-tissue tumors 258 

Constitution of bone in rachitis.... 133 
Constitutional diseases affecting 

teeth 61 

Constructive defects 91 

pathology 269 

"Core" of an abscess 207 

Cornea, inflammation of 200 

Crustapetrosa 33 

Cysts 232 

dermoid, with teeth 272 

Dalrymple on caries .'. 168 

Darwin, Charles 98 

Dead teeth 145 

Death from carcinoma 255 

Decomposition in the mouth 175 

of the teeth by acids 76 



275 



276 



INDEX. 



PAGE 

Defective denture 55 

1 (elects associated with cleft palate 90 

Deficiency of teeth 116 

Deformed molar teeth 55 

Deformity of jaw 118 

Delayed eruption 68 

Dental cap 105 

canal (or foramen) 18 

diseases of digestive origin.. 67 

foramen 22 

groove 33 

profession and infant foods.. 71 

Dentition 35 

in rachitis 136 

Denture,adult 53 

influence of general health 

upon 65 

Dermoid cysts 272 

Destruction of teeth in children... 69 

Development of facial bones 22 

of inferior maxillary 21 

of jaw for adult denture 53 

of maxillary bones 84 

of superior maxillary 15 

of the tooth 33 

Developmental defects 63 

Deviation of teeth from morbid 

growths 131 

Diabetes mellitus and saliva 30 

Difference between caries of teeth 

and that of bones 163 

Differentiation of pathological 

growths 23-1 

Digestive disturbances and dental 

disease 67 

Digitaline 31 

Disease, malignant, local nature of 264 
Displacement of germs of molar 

teeth 56 

Distinction between carcinoma 

and sarcoma 259 

Dog-teeth 72 

Duct, Steno's 27 

sublingual 28 

Wharton's , 28 

Embryonic branchial arches 22 

connective tissue 230 

maxillary bones 84 

Eminentia articularis 20 

pyramidalis 24 

Enamel germ 104 

of permanent teeth.... 107 

organ 34, 104 

Enchondroma 273 

Enlargement of alveolus for sec- 
ondary teeth 112 

Epithelial structures 107 

Epithelium, growth of 243 

in carcinoma 248 

Epulis 132 

Erosion of teeth 167 

Eruption, delayed 68 

of second denture 50 

of teeth 36 



PAGE 

Exostosis 212 

Extension of tumors 226 

External carotid artery 26 

oblique line 18 

Extrusion of teeth 74 

of teeth from sarcoma 262 

Exudation, inflammatory 188 

Face, bones of 14 

Facial artery 26 

artery, location of 17 

paralysis 59 

Fatty degeneration of tooth-pulp.. 143 

tumors 224 

Felon, description of. 205 

Fermentation in the mouth 175 

Fissure of upper lip (cleft) 89 

Fissures of enamel 73, 167 

Fluctuation of pus, etc 233 

Food for infants 70 

Foreign matters around the teeth. 76 

Form of face (structure) 14 

Formation of bone in other struc- 
tures 154 

of tumors 220 

Formula of second dentition 52 

Fractures, healing of 212 

Frontal process 23 

Functional diseases 182 

Fungi in caries 173 

Fused teeth, description of 130 

Fusion of adjacent teeth 128 

of molars 55 

of molars, diagnosis 128 

Gangrene of tooth pulp 147 

General pathology of the teeth 61 

Genial tubercles 18 

Glands, salivary 26 

salivary, character of 29 

Germs of molar teeth 54 

Granulation tissue 85, 231 

Growth of lower jaw 18 

Growths, malignant 220 

Hare-lip 24 

Head, form of 14 

form of in insanity 15 

Healing of fractures 212 

Hereditary diseases of teeth 119 

Polydactyly 237 

transmission of disease 116 

Heterologous growths 221 

Histological character of carcinoma 255 

development of teeth 99 

Homans' case of dermoid teeth 271 

Homologous growths 221 

Honeycombed teeth 166 

Hypersemia 188 

Hyperostosis 212 

Hypertrophy 212,236 

inflammatory 189 

of bone 156 

of teeth 237 



277 



PAGE 

Idiopathic abscess of tooth 151 

inflammation of tooih 139 

Induration inflammatory 198 

Infant food 70 

Infantile indigestion 71 

jaw 93 

teeth, retention of 44 

Inferior dental artery 18 

dental canal 18 

dental nerve 18 

maxillary bone 17 

maxillary process 22 

Inflammation 187 

cardinal symptoms 189 

of bloodless tissues 200 

of hard structures and of 

teeth 208 

of teeth 137 

Influence of remedies on the hard 

tissues 65 

Infra-orbital foramen 16 

Infra-orbital nerve 16 

Inner nasal process 23 

Insanity, form of head in 15 

Intermaxillary process and bone... 23 

Internal carotid artery 27 

jugular vein 27 

maxillary artery 26 

metastases of sarcoma 264 

Invasion of lymphatics by carci- 
noma 253 

Jaborandi, action of on salivary 

glands 30 

Jaw, changes in 21 

condition of in sarcoma 262 

deformity of from retained 

teeth 44 

in adult denture 53 

lateral motions in 20 

lower 17, 22 

development of. 21 

variation in sha;ie of... 22 

sarcoma of 261 

upper 15 

Klencke on central caries 159 

Lamprey, tooth of 32 

Leber on caries 169 

Leptothrix buccalis 27 

in health 80 

Lloyd, Jordan, case of odontome... 269 

Lipoma 224 

Lister system of antiseptic treat- 
ment 149 

Local character of maliguant dis- 
ease 264 

Lockjaw 62 

Lower jaw 17 

Magitot on caries 170 

Malignancy of sarcoma 261 



PAGE 

Malignancy of tumors 221 

Mal-nutrition in children 68 

Mantegazzaon caries 168 

Marasmus 255 

Mastication, imperfect, from re- 
tained teeth 46 

Maxillary bones in the embryos... 84 

bones, ossification of 86 

tuberosity 16 

Meckel's cartilage 24 

Mental foramen 18,21 

prominence 17 

Mercury, action of, on salivary 

glands 30 

Metastasis of carcinoma 251 

of sarcoma 263 

Metastatic growths 227 

Migration of bacterial organisms... 82 

of blood cells 196 

Molar teeth, origin of 54 

"Mother's Mark" 225 

Muscarine 31 

Nasal process 23 

Naso-buccal fistula 59 

Necrosis of alveolar process 73 

from pressure 206 

of bone 157,208 

of jaw 74 

Nerves of pulp 33 

Neuralgia from tumors 185 

from syphilis 186 

Neuroses of the teeth and face 179 

reflex 182 

Nicotine 31 

Nutrition 38 

disorders of 61 

Odontoblasts 33 

Odontome, Lloyds' case of. 269 

Operation for neuralgia 184 

for retained teeth 57 

for sarcoma 263 

Order of eruption of teeth 36 

Organic diseases 182 

Origin of carcinoma 242 

of caries 160 

of congenital malforma- 
tions 115 

of disordered denture 72 

of molar teeth 54 

of sarcoma 260 

Original human denture 113 

Ossification of lower jaw 85 

of maxillary bones 86 

Pain in tooth, cause of 137 

Palate-cleft, origin of 87 

Papilla of tooth 32 

Paralysis of face 59 

of facial muscles 234 

of secretory nerves 31 



278 



INDEX. 



PAGE 

Parasitic growths 226 

organisms of the mouth 79 

Parotid gland 26 

gland, tumors of 266 

saliva 27 

Pathological nomenclature 228 

Pathology, constructive 269 

delinition of 14 

of second dentition 108 

Penetration of tissues hy bacteria 82 

Peridental membrane 33 

Periosteum 33 

Physiological loss of teeth 52 

Physostigmine 31 

Phosphorus, necrosis from 210 

Pilocarpine 31 

Poison, effect of on salivary glands 31 

Polydactyly, hereditary 237 

Posterior auricular artery 26 

Pregnancy, influence of, upon the 

teeth 140 

Primary denture, situation of.... 19 
Processes of superior maxillary 

bone 15 

Processus folii 24 

Progress of inflammation of tooth 139 

Pterygoid processes, origin of 24 

Ptyahn 28 

Pulp of tooth 33 

Pulp-stones 177 

from secondary dentine 268 

Pus, calcareous 218 

cheesy 218 

white blood-corpuscles in 198 

Rachitic bone, composition of. 134 

Rachitis 132 

Ramus of lower jaw, changes in... 20 

Reaction of saliva 30 

Reflex neurosis 182 

Regurgitation from stomach 74 

Removal of callus 48 

of malignant growths 264 

Repair of hard tissues 47 

Results of inflammation 214 

Retained wisdom teeth 55, 126 

Rete mucosum 243 

Retention of deciduous teeth 44 

cysts 233 

Rheumatic enlargements 225 

Rottenstein on caries 169 

Saliva, action of 19 

in disease (acid) 69 

of rabid animals and snakes 30 

specific gravity of. 30 

submaxillary 28 

Salivary calculus 27 

fistula 30 

26 

effect of poisons on 31 

Sarcoma 258 

Scar 207 

Seat of neuroses 179 



PAGE 

Secondary dentine 177, 268 

dentition 43 

formula of. 52 

pathology of 108 

denture, eruption of. 50 

enamel germ., 35 

metastasis 254 

Secretion of saliva 30 

of salivary glands 29 

Septicaemia from caries 161 

Septum of nose 23 

Sequestrum 209 

Sinus of alveolar process 55 

of jaw 43 

of retained wisdom tooth... 126 

Size of teeth 121 

Skeleton of face 14 

Skull, tumors of base of 266 

Slough 206 

Slow eruption of teeth 68 

Softening of bones from sarcoma... 262 

Source of acids in the mouth 171 

Speech, defective, from retained 

milkteeth 46 

Spina bifida 90 

Spontaneous cure of caries 177 

Spread of carcinoma 254 

Steno's duct 27 

Strength of lower jaw 86 

Structure of teeth 32 

Sub-lingual gland 28 

Sub-maxillary gland 27 

Sugar from action of saliva 29 

Superior maxillary bone, forma- 
tion of. 15 

processes 22 

Suppuration 188 

of alveolus 55 

of antrum 59 

of glands 71 

of tooth-pulp 143 

Syphilis, influence of in producing 

malformations 116 

Systemic effects of deficient den- 
ture 69 

Tartar 27 

Teeth affected by foreign sub- 
stances 76 

dermoid 272 

destroyed by systemic dis- 
ease 68 

eruption, order of 36 

extrusion of. 262 

fusion of 128 

in relation to bacteria 78 

Temporal artery 26 

Tetanus 62 

Tic douloureux, seat of. 16 

Tobacco, action of on salivary 

glands 31 

Tongue, formation of 23 

Tooth germs 100 

sac 34 



INDEX. 



279 



PAGE 

Tooth, tumors of 267 

Tuberculosis 219 

Tumors 220 

of parotid gland 266 

of the upper jaw 265 

Tusks of elephant 151 

Ulceration in carcinoma 252 

of teeth (see Alveolar inflam- 
mation) 150 



PAGE 

Variation in number of teeth 114 

in tissues of tumors 231 

Virehow on pathological growths.. 232 

Wen 247 

Westcott on caries 168 

Wharton's duct 28 

Wisdom teeth, deformity of 19 

teeth, malposition of. 125 

teeth, retained 126 

Wolf-teeth 72 



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O. L. Potter, m.a., m.d., Professor of the Practice of 
Medicine in Cooper Medical College, San Francisco, 
Late A. A. Surg., U. S. A., Author of the " Quiz- 
Compends" of Anatomy and Materia Medica, etc. 
This book contains many unique features of style and arrange- 
ment ; no time or trouble has been spared to make it most complete 
and yet concise in all its parts. It contains many prescriptions of 
practical worth, a great mass of facts conveniently and concisely 
put together, also many tables, dose lists, diagnostic hints, etc., 
all rendering it the most complete manual ever published. 

" Dr. Potter's handbook will find a place, and a very important 
one, in our colleges and the libraries of our practitioners." — N. Y. 
Medical Journal. 

No. 6. DISEASES OP CHILDREN. 

A Manual. By J. F. Goodhart, m.d., Phys. to the 
Evelina Hospital for Children ; Asst. Phys. to 
Guy's Hospital, London. American Edition. Edited 
by Louis Starr, m.d., Clinical Prof, of Dis. of 
Children in the Hospital of the Univ. of Pennsylvania, 
and Physician to the Children's Hospital, Phila. 
Containing many new Prescriptions, a list of over 50 
Formulae, conforming to the U. S. Pharmacopoeia, and 
Directions for making Artificial Human Milk, for the 
Artificial Digestion of Milk, etc. 

"As it is said of some men, so it might be said of some books, 
that they are 'born to greatness.' This new volume has, we 
believe, a mission, particularly in the hands of the younger 
members of the profession. In these days of prolixity in medical 
literature, it is refreshing to meet with an author who knows both 
what to say and when he has said it. The work of Dr. Goodhart 
Price of each Book, Cloth, $3.00. Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



(admirably conformed, by Dr. Starr, to meet American require- 
ments) is the nearest approach to clinical teaching without the 
actual presence of clinical material that we have yet seen." — New 
York Medical Record. 

No 7- PRACTICAL THERAPEUTICS. 

FOURTH EDITION, WITH AN INDEX OF DISEASES. 

Practical Therapeutics, considered with reference to 
Articles of the Materia Medica. Containing, also, an 
Index of Diseases, with a list of the Medicines 
applicable as Remedies. By Edward John Waring, 
M.D., f.R.C.p. Fourth Edition. Rewritten and Re- 
vised. By Dudley W. Buxton, m.d., Asst. to the 
Prof, of Medicine at University College Hospital. 
"We wish a copy could be put in the hands of every Student or 
Practitioner in the country. In our estimation, it is the best book 
of the kind ever written."— Af. Y. Medical Journal. 

No. 8. MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

By John J. Reese, M.D., Professor of Medical Jurispru- 
dence and Toxicology in the University of Pennsyl- 
vania; Vice-President of the Medical Jurisprudence 
Society of Phila. ; Physician to St. Joseph's Hospital. 
"This admirable text-book." — Amer. Jour, of Med. Sciences. 
" We lay this volume aside, after a careful perusal of its pages, 
with the profound impression that it should be in the hands of every 

doctor and lawyer. It fully meets the wants of all students 

He has succeeded in admirably condensing into a handy volume all 
the essential points." — Cincinnati Lancet and Clinic. 

No. 9. ORGANIC CHEMISTRY. 
Or the Chemistry of the Carbon Compounds. By Prof. 
Victor von Richter, University of Breslau. Au- 
thorized translation, from the Fourth German Edition. 
By Edgar F. Smith, m.a., ph.d. ; Prof, of Chemistry 
in Wittenberg College, Springfield, Ohio ; formerly in 
the Laboratories of the University of Pennsylvania; 
Member of the Chem. Socs. of Berlin and Paris. 

" I must say that this standard treatise is here presented in a 
remarkably compendious shape. "— _/• W. Holland, M.D., Professor 
of Chemistry, Jefferson Medical College, Phi'adelphia. 

" This work brings the whole matter, in simple, plain language, 
to the student in a clear, comprehensive manner. The whole 
method of the work is one that is more readily grasped than that of 
older and more famed text-books, and we look forward to the time 
when, to a great extent, this work will supersede others, on the 
score of its better adaptation to the wants of both teacher and 
student." — Pharmaceutical Record. 



Price of each Book, Cloth, $3.00. Leather, $3.50. 



6 STUDENTS' TEXT-BOOKS A-ND MANUALS. 

ANATOMY. 

Holden's Anatomy. A manual of Dissection of the Human 
Body. Fifth Edition. Enlarged, with Marginal References and 
over 200 Illustrations. Octavo. Cloth, 5.00; Leather, 6.00 

Bound in Oilcloth, for the Dissecting Room, $4.50, 

" No student of Anatomy can take up this book without being 
pleased and instructed. Its Diagrams are original, striking and 
suggestive, giving more at a glance than pages of text description. 
* * * The text matches the illustrations in directness of prac- 
tical application and clearness of detail." — New York Medical 
Record, 

Holden's Human Osteology. Comprising a Description of the 
Bones, with Colored Delineations of the Attachments of the 
Muscles. The General and Microscopical Structure of Bone and 
its Development. With Lithographic Plates and Numerous Illus- 
trations. Sixth Edition. 8vo. Cloth, 6.00 

Heath's Practical Anatomy. Sixth London Edition. 24 Col- 
ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 

Potter's Compend of Anatomy. Fourth Edition. 117 Illus- 
trations. Cloth, 1. 00; Interleaved for Notes, 1.25 

CHEMISTRY. 

Bartley's Medical Chemistry. A text-book prepared specially 
for Medical, Pharmaceutical and Dental Students. With 40 
Illustrations, Plate of Absorption Spectra and Glossary of Chemi- 
cal Terms. Cloth, 2.50 

*#* This book has been written especially for students and phy- 
sicians. It is practical and concise, dealing only with those parts 
of chemistry pertaining to medicine ; no time being wasted in long 
descriptions of substances and theories of interest only to the 
advanced chemical student. 

Bloxam's Chemistry, Inorganic and Organic, with Experiments. 
Sixth Edition. Enlarged and Rewritten. Nearly 300 Illus- 
trations. Cloth, 4.50; Leather, 5.50 
Richter's Inorganic Chemistry. A text-book for Students. 
Third American, from Fifth German Edition. Translated by 
Prof. Edgar F. Smith, ph.d. 89 Wood Engravings and Colored 
Plate of Spectra. Cloth, 2.00 
Richter's Organic Chemistry, or Chemistry of the Carbon 
Compounds. Translated by Prof. Edgar F. Smith, ph.d. 
Illustrated. Cloth, 3.60; Leather, 3.50 
IS" See pages 2 to 5 for list of Students' Manuals . 



STUDENTS' TEXT-BOOKS AND MANUALS. 7 

Chemistry : — Continued. 

Trimble. Practical and Analytical Chemistry. A Course in 
Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- 
istry in the Phila. College of Pharmacy. Illustrated. Second 
Edition. 8vo. Cloth, 1.50 

Tidy. Modern Chemistry. 2d. Ed. Cloth, 5.50 

Leffmann's Compend of Chemistry. Organic and Medical. 
Cloth, 1.00; Interleaved for Notes, 1.25 

Muter. Practical and Analytical Chemistry. Second Edi- 
tion, Revised and Illustrated, Cloth, 2.00 

Holland. The Urine, Chemical and Microscopical. For 

Laboratory Use. Illustrated. Cloth, .50 

Van Niiys. Urine Analysis. Illus. Cloth, 2.00 

Wolff's Applied Medical Chemistry. By Lawrence Wolff, 

m.d., Demonstrator of Chemistry in Jefferson Medical College, 

Philadelphia. Cloth, 1.50 

CHILDREN. 

Goodhart and Starr. The Diseases of Children. A Manual 
for Students and Physicians. By J. F. Goodhart, m.d., Physi- 
cian to the Evelina Hospital for Children ; Assistant Physician 
to Guy's Hospital, London. American Edition, Revised and 
Edited by Louis Starr, m.d., Clinical Professor of Diseases of 
Children in the Hospital of the University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia. Containing 
many new Prescriptions, a List of over 50 Formulae, conforming 
to the U. S. Pharmacopoeia, and Directions for making Arti- 
ficial Human Milk, for the Artificial Digestion of Milk, etc. 
Cloth, 3.00; Leather, 3.50 

Day. On Children. A Practical and Systematic Treatise. 
Second Edition. 8vo. 752 pages. Cloth, 3.00; Leather, 4.00 

Meigs and Pepper. The Diseases of Children. Seventh 
Edition. 8vo. Cloth, 5.00; Leather, 6.00 

Starr. Diseases of the Digestive Organs in Infancy and 
Childhood. With chapters on the Investigation of Disease, 
and on the General Management of Children. Illus. Cloth, 2.50 

Keating and Edwards. Diseases of the Heart and Circulation 
in Infancy and Adolescence. Illustrated with Wood Engravings, 
Photographs and one Colored Plate. 8vo. Cloth, 1.50 

4®* See page lb for list of ? Quiz- Co mp ends ? 



8 STUDENTS' TEXT-BOOKS AND MANUALS. 

DENTISTRY. 

Flagg's Plastics and Plastic Filling. 3d Ed. Preparing. 
Gorgas. Dental Medicine. A Manual of Materia Medica and 

Therapeutics. Second Edition. Cloth, 3.25 

Harris. Principles and Practice of Dentistry. Including 

Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery 

and Mechanism. Eleventh Edition. Revised and enlarged by 

Professor Gorgas. 744 Illustrations. Cloth, 6.50 ; Leather, 7.50 
Richardson's Mechanical Dentistry. Fourth Edition. 458 

Illustrations. 710 pages. 8vo. Cloth, 4.50; Leather, 5.50. 

Stocken's Dental Materia Medica. Third Edition. Cloth, 2.50 
Taft's Operative Dentistry. Dental Students and Practitioners. 

Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 
Talbot. Irregularities of the Teeth, and their Treatment. 

Illustrated. 8vo. ■ Cloth, 2.00 

Tomes' Dental Anatomy, Human and Comparative. Third 

Edition. 191 Illustrations. Preparing. 

Tomes' Dental Surgery. Third Edition. Revised. 292 

Illustrations. 772 Pages. Cloth, 5.00 

DICTIONARIES. 

Cleaveland's Pocket Medical Lexicon. Thirty-first Edition. 

Giving correct Pronunciation and Definition of Terms used in 

Medicine and the Collateral Sciences. Very small pocket size, 

Cloth, red edges .75 ; pocket-book style, 1.00 

Longley's Pocket Dictionary. The Student's Medical Lexicon, 
giving Definition and Pronunciation of all Terms used in Medi- 
cine, with an Appendix giving Poisons and Their Antidotes, 
Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
241110. Cloth, 1. 00; pocket-book style, 1.25 

EYE. 

Arlt. Diseases of the Eye. Including those of the Conjunc- 
tiva, Cornea, Sclerotic, Iris and Ciliary Body. By Prof. Von 
Arlt. Translated by Dr. Lyman Ware. Illus. 8vo. Cloth, 2.50 

Hartridge on Refraction. 3d Ed. Cloth, 2.00 

Macnamara. On Diseases of the Eye. Fourth Edition. 
Revised. Colored Plates and Wood Cuts and Test Types. 

Cloth, 4.00 

Meyer. Diseases of the Eye. A complete Manual for Stu- 
dents and Physicians. 270 Illustrations and two Colored Plates. 
8vo. Just Ready. Cloth, 4.50; Leather, 5.50 

Morton. Refraction of the Eye. Third Ed. Illus. Cloth, 1.00 

Fox and Gould. Compend of Diseases of the Eye and 
Refraction. 60 Illus. Cloth, 1. 00; Interleaved for Notes, 1.25 

JQQrSee pages 2 to 5 for list of Students' Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 9 

ELECTRICITY. 

Mason's Compend of Medical and Surgical Electricity. 
With numerous Illustrations. i2mo. See page ij. Cloth, i.oo 

HYGIENE. 
Park'es' Practical Hygiene. Seventh Edition, enlarged. Illus- 
trated. 8vo. Cloth, 4.50 
Wilson's Handbook of Hygiene and Sanitary Science. 

Sixth Edition. Revised and Illustrated. Cloth, 2.75 

MATERIA MEDICA AND THERAPEUTICS. 

Potter's Compend of Materia Medica, Therapeutics and 

Prescription Writing. Fifth Edition, revised and improved. 

Cloth, 1.00; Interleaved for Notes, 1.25 

Biddle's Materia Medica. Tenth Edition. For the use of 
Students and Physicians. By the late Prof. John B. Biddle, m.d., 
Professor of Materia Medica in Jefferson Medical College, Phila- 
delphia. The Tenth Edition, thoroughly revised, and in many 
parts rewritten, by his son, Clement Biddle, m.d., Past Assistant 
Surgeon, U. S. Navy, assisted by Henry Morris, m.d., Demon- 
strator of Obstetrics in Jefferson Medical College. 8vo., illus- 
trated. Cloth, 4.00 ; Leather, 4.75 

" The larger works usually recommended as text-books in our 
medical schools are too voluminous for convenient use. This work 
will be found to contain in a condensed form all that is most valuable, 
and will supply students with a reliable guide." — Chicago Med. Jl. 
Headland's Action of Medicines. 9th Ed. 8vo. Cloth, 3.00 
Potter. Materia Medica, Pharmacy and Therapeutics. 
Including Action of Medicines, Special Therapeutics, Pharma- 
cology, etc. Page 4. Cloth, 3.00; Leather, 3.50. 
Roberts' Compend of Materia Medica and Pharmacy. By the 
author of "Roberts' Practice." Cloth, 2.00 
Starr, Walker and Powell. Synopsis of Physiological 
Action of Medicines, based upon Prof. H. C. Wood's " Materia 
Medica and Therapeutics." 3d Ed. Enlarged. Cloth, .75 
Waring. Therapeutics. With an Index of Diseases and an 
Index of Remedies. A Practical Manual. Fourth Edition. 
Revised and Enlarged. Cloth, 3.00; Leather, 3.50 

MEDICAL JURISPRUDENCE. 

Reese. A Text-book of Medical Jurisprudence and Toxi- 
cology. By John J. Reese, m.d., Professor of Medical Juris- 
prudence and Toxicology in the Medical and Law Departments 
of the University of Pennsylvania ; Vice-President of the Med- 
ical Jurisprudence Society of Philadelphia ; Physician to St. 

$8f See page 16 for list of ? Quiz-Cempends ? 



10 STUDENTS' TEXT-BOOKS AND MANUALS. 

Medical Jurisprudence : — Continued. 
Joseph's Hospital ; Corresponding Member of The New York 
Medico-legal Society. Cloth, 3.00; Leather, 3.50 

Abercrombie's Students' Guide to Medical Jurisprudence. 
i2mo. Cloth, 2.50 

Mann's Manual of Psychological Medicine, and Allied Ner- 
vous Diseases. Their Diagnosis, Pathology and Treatment, and 
their Medico-Legal Aspects. Illus. Cloth, 5.00 ; Leather, 6.00 

■Woodman and Tidy's Medical Jurisprudence and Toxi- 
cology. Chromo-Lithographic Plates and 116 Wood engravings. 
Cloth, 7.50; Leather, 8.50 

MISCELLANEOUS. 

Allingham. Diseases of the Rectum. Fourth Edition. Illus- 
trated. 8vo. Paper covers, .75 ; Cloth, 1.25 

Beale. Slight Ailments. Their Nature and Treatment. Illus- 
trated. 8vo. Paper cover, .75 ; Cloth, 1.25 

Fothergill. Diseases of the Heart, and Their Treatment. 
Second Edition. 8vo. Cloth, 3.50 

Gowers. Diseases of the Nervous System. 400 Illus- 
trations. Cloth, 6.50; Leather, 7.50 

Tanner. Memoranda of Poisons. Their Antidotes and Tests, 
Sixth Edition. Revised by Henry Leffmann, m.d. 

Cloth, .75 

OBSTETRICS AND GYNECOLOGY. 

Byford. Diseases of Women. The Practice of Medicine and 
Surgery, as applied to the Diseases and Accidents Incident to 
Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology 
in Rush Medical College and of Obstetrics in the Woman's Med- 
ical College, etc., and Henry T. Byford, m.d., Surgeon to the 
Woman's Hospital of Chicago ; Gynaecologist to St. Luke's 
Hospital, etc. Fourth Edition. Revised, Rewritten and En- 
larged. With 306 Illustrations, over 100 of which are original 
Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 

Parvin's Winckel's Diseases of 'Women. Edited by Prof. 
Theophilus Parvin, Jefferson Medical College, Philadelphia. 
117 Illustrations. See page 3. Cloth, 3.00; Leather, 3.50 

Morris. Compend of Gynaecology. Illustrated. In Press. 

4®=- See pages 2 to 5 for list of Ne-jj Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 11 

Obstetrics and Gynecology : — Continued. 

Landis' Compend of Obstetrics. Illustrated. 3d edition. 
Cloth, 1. 00 ; Interleaved for Notes, 1.25 

Galabin's Midwifery. A New Manual for Students. By A. 
Lewis Galabin, m.d., f.r.c.p., Obstetric Physician to Guy's 
Hospital, London, and Professor of Obstetrics in the same Insti- 
tution. 227 Illustrations. Cloth, 3.00; Leather, 3.50 

Glisan's Modern Midwifery. 2d Edition. Cloth, 3.00 

Rigby's Obstetric Memoranda. By Alfred Meadows, m.d. 
4th Edition. Cloth, .50 

Meadows' Manual of Midwifery. Including the Signs and 
Symptoms of Pregnancy, Obstetric Operations, Diseases of the 
Puerperal State, etc. 145 Illustrations. 494 pages. Cloth, 2.00 

Swayne's Obstetric Aphorisms. For the use of Students 
commencing Midwifery Practice. 8th Ed. i2mo. Cloth, 1.25 

PATHOLOGY AND HISTOLOGY. 

Bowlby. Surgical Pathology and Morbid Anatomy, for 
Students. 135 Illustrations, nmo. Cloth, $2.00 

Rindfleisch's General Pathology. By Tyson. For Students 
and Physicians. By Prof. Edward Rindfleisch, of Wurzburg. 
Translated by Wm. H. Mercur, m.d., of Pittsburgh, Pa. Edited 
by James Tyson, m.d., Professor of Pathology and Morbid 
Anatomy in the University of Pennsylvania. i2mo. Cloth, 2.00 
Gilliam's Essentials of Pathology. A Handbook for Students. 
47 Illustrations, nmo. Cloth, 2.00 

*:js*The object of this book is to unfold to the beginner the funda- 
mentals of pathology in a plain, practical way, and by bringing 
them within easy comprehension to increase his interest in the study 
of the subject. 

Gibbes' Practical Histology and Pathology. Third Edition. 
Enlarged. i2mo. Cloth, 1.75 

PHYSICAL DIAGNOSIS. 

Bruen's Physical Diagnosis of the Heart and Lungs. By 
Dr. Edward T. Bruen, Assistant Professor of Clinical Medicine 
in the University of Pennsylvania. Second Edition, revised. 
With new Illustrations. i2mo. Cloth, 1.50 

***The subject is treated in a plain, practical manner, avoiding 
questions of historical or theoretical interest, and without laying 
special claim to originality of matter, the author has made a book 
that presents to the student the somewhat difficult points of Physi- 
cal Diagnosis clearly and distinctly. 

PHYSIOLOGY. 

Yeo's Physiology. Third Edition. The most Popular Stu- 
dents' Book. By Gerald F. Yeo, m.d., f.r.c.s., Professor of 
#g~ See page lb for list of ?Quiz-Compends > 



12 STUDENTS' TEXT-BOOKS AND MANUALS. 

Physiology : — Continued. 
Physiology in King's College, London. Small Octavo. 758 
pages. 321 carefully printed Illustrations. With a Full 
Glossary and Index. See Page 3, Cloth, 3.00; Leather, 3.50 

Brubaker's Compend of Physiology. Illustrated. Fourth 
Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 

Stirling. Practical Physiology, including Chemical and Ex- 
perimental Physiology. 142 Illustrations. Cloth, 2.25 
Kirke's Physiology, nth Ed. Illus. Cloth, 4.00; Leather, 5.00 
Landois' Human Physiology. Including Histology and Micro- 
scopical Anatomy, and with special reference to Practical Medi- 
cine. Second Edition. Translated and Edited by Prof. Stirling. 
583 Illustrations. Cloth, 6.50; Leather, 7.50 
" So great are the advantages offered by Prof. Landois' Text- 
book, from the exhaustive and eminently practical manner in which 
the subject is treated, that, notwithstanding it is one of the largest 
works on Physiology, it has yet passed through four large editions 
in the same number of years. Dr. Stirling's annotations have 
materially added to the value of the work. . . . Admirably 
adapted for the practitioner. . . . With this Text-book at his 
command, no student could fail in his examination." — Lancet. 
Sanderson's Physiological Laboratory. Being Practical Ex- 
ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 
Tyson's Cell Doctrine. Its History and Present State. Illus- 
trated. Second Edition. Cloth, 2.00 
PRACTICE. 
Roberts' Practice. New Revised Edition. A Handbook 
of the Theory and Practice of Medicine. By Frederick T. 
Roberts, m.d. ; m.r.c.p., Professor of Clinical Medicine and 
Therapeutics in University College Hospital, London. Seventh 
Edition. Octavo. In Press. 
Hughes. Compend of the Practice of Medicine. 3d Ed. 
Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25. 
Part i. — Continued, Eruptive and Periodical Fevers, Diseases 
of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
Kidneys, etc., and General Diseases, etc. 

Part ii. — Diseases of the Respiratory System, Circulatory 
System and Nervous System; Diseases of the Blood, etc. 
Tanner's Index of Diseases, and Their Treatment. Cloth, 3.00 
" This work has won for itself a reputation. ... It is, in 
truth, what its Title indicates."— iV. Y. Medical Record. 

PRESCRIPTION BOOKS. 

Wythe's Dose and Symptom Book. Containing the Doses 
and Uses of all the principal Articles of the Materia Medica, etc. 
Seventeenth Edition. Completely Revised and Rewritten. Just 
Ready. 32mo. Cloth, 1. 00: Pocket-book style, 1.25 

Pereira's Physician's Prescription Book. Containing Lists 
of Terms, Phrases, Contractions and Abbreviations used in 
Prescriptions, Explanatory Notes, Grammatical Construction of 
Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
Sixteenth Edition. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 

J&g=-See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 



PHARMACY. 



Stewart's Compend of Pharmacy. Based upon Remington's 
Te*t Book of Pharmacy. ■ Second Edition, Revised. 

Cloth, i.oo; Interleaved for Notes, 1.25. 

SKIN DISEASES. 

Anderson, (McCall) Skin Diseases. A complete Text-Book, 

with Colored Plates and numerous Wood Engravings. 8vo. 

Just Ready. Cloth, 4.50; Leather, 5.50 

" We welcome Dr. Anderson's work not only as a friend, but as 

a benefactor to the profession, because the author has stricken off 

mediaeval shackles of insuperable nomenclature and made crooked 

ways straight in the diagnosis and treatment of this hitherto but 

little understood class of diseases. The chapter on Eczema is 

alone worth the price of the book." — Nashville Medical News. 

" Worthy its distinguished author in every respect ; a work whose 
practical value commends it not only to the practitioner and stu- 
dent of medicine, but also to the dermatologist."— James Nevens 
Hyde, m.d., Prof, of Skin and Venereal Diseases, Rush Medical 
College, Chicago. 

Van Harlingen on Skin Diseases. A Handbook of the Dis- 
eases of the Skin, their Diagnosis and Treatment. By Arthur 
Van Harlingen, m.d., Prof, of Diseases of the Skin in the Phila- 
delphia Polyclinic; Consulting Physician to the Dispensary 
for Skin Diseases, etc. With colored plates. i2mo. Cloth, 1.75 
Bulkley. The Skin in Health and Disease. By L. Duncan 
Bulkley, Physician to the N. Y. Hospital. Illus. Cloth, .50 

SURGERY. 

Heath's Minor Surgery, and Bandaging. Eighth Edition. 142 
Illustrations. 60 Formula and Diet Lists. Cloth, 2.00 

Horwitz's Compend of Surgery, including Minor Surgery, 
Amputations, Fractures, Dislocations, Surgical Diseases, and the 
Latest Antiseptic Rules, etc., with Differential Diagnosis and 
Treatment. By Orville Hokwitz, e.s., m.d., Demonstrator of 
Anatomy, Jefferson Medical College ; Chief, Out- Patient Surgi- 
cal Department, Jefferson Medical College Hospital. 3d edition. 
Very much Enlarged and Rearranged. 91 Illustrations and 
77 Formulae. i2mo. No. q ? Quiz-CumJ>end ? Series. 

Cloth, 1.00 ; Interleaved for the addition of Notes, 1.25. 

Pye's Surgical Handicraft. A Manual of Surgical Manipula- 
tions, Minor Surgery, Bandaging, Dressing, etc., etc. With 
special chapters on Aural Surgery, Extraction of Teeth, Anaes- 
thetics, etc. 208 Illustrations. 8vo. . Cloth, 5.00 

Swain's Surgical Emergencies. New Edition. Illus. Clo., 1.50 

Walsham. Manual of Practical Surgery. For Students and 
Physicians. By Wm. J. Walsham, m.d., f.r c.s., Asst. Surg, 
to, and Dem. of Practical Surg, in, St. Bartholomew's Hospital, 
Surgeon to Metropolitan Free Hospital, London. With 236 
Engravings. See Page 2. Cloth, $3.00 ; Leather, $3. 50 

Watson on Amputation of the Extremities, and their Compli- 
cations. 2 colored plates and 250 wood cuts. 8vo. Cloth, 5.50 

4S~ See page ibfor list of ? Quiz-Compends ? 



14 STUDENTS' TEXT-BOOKS AND MANUALS. 

THROAT. 

Mackenzie on the Throat and Nose. New Edition. By 
Morell Mackenzie, m.d., Senior Physician to the Hospital for 
Diseases of the Chest and Throat; Lecturer on Diseases of the 
Throat at the London Hospital, etc. Revised and Edited by 
D. Bryson Delavan, m.d., Prof, of Laryngology and Rhinology 
in the N. Y. Polyclinic; Chief of Clinic, Department of Diseases 
of the Throat, College of Physicians and Surgeons, N. Y. ; Sec'y 
of the Amer. Laryngological Assoc, etc. Complete in one vol- 
ume, over 200 Illustrations, and many formulae. Octavo. 

Diseases of the Oesophagus, Nose and Naso-Pharynx, with 

Formulae and 93 Illustrations. Cloth, 3.00; Leather, 4.00 

" It is both practical and learned ; abundantly and well illustrated ; 
its descriptions of disease are graphic and the diagnosis the best we 
have anywhere seen." — Philadelphia Medical Times. 

Cohen. The Throat and Voice. Illustrated. "Cloth, .50 

James. Sore Throat. Its Nature, Varieties and Treatment. 

i2mo. Illustrated. Paper cover, .75; Cloth, 1.25 

URINE, URINARY ORGANS, ETC. 

Acton. The Reproductive Organs. In Childhood, Youth, 
Adult Life and Old Age. Sixth Edition. Cloth, 2.00 

Beale. Urinary and Renal Diseases and Calculous Disorders. 
Hints on Diagnosis and Treatment. i2mo. Cloth, 1.75 

Holland. The Urine. Chemical and Microscopical, for Labo- 
ratory Use. Illustrated. Cloth, .50 

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- 
trations. 12^10. 572 pages. Cloth, 2.75 

Legg. On the Urine. A Practical Guide. 6th Ed. Cloth, .75 

Marshall and Smith. On the Urine. The Chemical Analysis ot 
the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. 
of Penna ; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 

Thompson. Diseases of the Urinary Organs. Seventh 
Edition. Illustrated. Cloth, 1.25 

Tyson. On the Urine. A Practical Guide to the Examination 
of Urine. With Colored Plates and Wood Engravings. 5th Ed. 
Enlarged. 12 mo. Cloth, 1.50 

Van Nuys, Urine Analysis. Illus. Cloth, 2.00 

VENEREAL DISEASES. 

Hill and Cooper. Student's Manual of Venereal Diseases, 
with Formulae. Fourth Edition. i2mo. Cloth, 1.00 

Durkee. On Gonorrhoea and Syphilis. Illus. Cloth, 3.50 
4®°* See page ib for list of ? Quiz-Co?npends ? 



MEDICAL BRIEFS. 

A new series of short, concise compends for the Med- 
ical Student and Practitioner. 

i2mo. Cloth. Price of Each Book, $1.00. 

No. i. POST-MORTEM EXAMINATIONS 

With Especial Reference to Medico- Legal Practice 
By Prof. Rudolph Virchow, of Berlin Charite Hos 
pital, author of Cellular Pathology ; Translated by T 
P. Smith, m.d., Member of the Royal College of Sur 
geons of England. 2d American, from the 4th German 
Edition. With new Plates. Illustrated by Four Lith- 
ographs. 

" We are informed in precise and exact terms how a post-mortem 
examination should be made, both with regard to the plan to be 
pursued, and the manner of making the several cuts into the various 
organs and tissues. The method of recording the results of the 
investigation is clearly indicated by the addition of the detailed 
account of the examination of four cases ; and the value of the ob- 
jective evidence is accurately stated in the form of the inferences 
drawn concerning the manner and cause of death." — American 
Journal of Medical Sciences. 

No. 2. MANUAL OF VENEREAL DISEASES. 

A Concise Description of those Affections and of their 
Treatment, including a list of Sixty-seven Prescrip 
tions for Vapor Bath, Gargles, Injections, Lotions 
Mixtures, Ointments, Paste, Pills, Powders, Solutions 
and Suppositories. By Berkeley Hill, m.d., Pro 
fessor of Clinical Surgery in University College; Sur 
geon to University College and Lock Hospitals; and 
Arthur Cooper, m.d., formerly House Surgeon, Lock 
Hospital, London. 4th Edition, Revised and Enlarged 

'* I have examined it with care, and find it to be a practical and 
useful compendium of knowledge on the subjects discussed, well 
adapted to the use of medical students and those physicians in 
general practice who have occasional need to consult a work of this 
kind." — James Neven-Hyde , m.d., Prof essor of Skin and Venereal 
Diseases, Rush Medical College, Chicago. 

No. 3. MEDICAL ELECTRICITY. A Com- 
pend of Electricity and its Medical and Surgical Uses. 
By Chas. F. Mason, m.d., Ass't Surg. U. S. Army ; 
with an introduction by Charles H. May, m.d., 
Instructor in Ophthalmology, New York Polyclinic. 
Illustrated. Just Ready. 

OTHER VOLUMES IN PREPARATION. 
Price of Each Book, bound in Cloth, Si.co. 



PQUIZ-COMPENDS? 

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Price of each Book, Cloth, $1.00; Interleaved, i. 25. 

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A. Surg. U. S. A. Fourth Edition. 117 Illustrations. 

II. PRACTICE. Part 1. By Dan'l E. Hughes, 
m.d., late Demonstrator of Clinical Medicine in 
Jefferson College. Third Edition, Enlarged. 

III. PRACTICE. Part 11. Same author as above. 
Third Edition, Enlarged. 

IV. PHYSIOLOGY. By A. P. Brubaker, Demon- 
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phia. Fourth Edition, Improved. New Illustrations. 

V. OBSTETRICS. By Prof. Henry G. Landis, 
Third Edition. Illustrated. 

VI. MATERIA MEDICA, THERAPEUTICS 
AND PRESCRIPTION WRITING. By Prof. 
Sam'l O. L. Potter. 5th Ed., Enlarged and Imp. 

VII. GYN/ECOLOGY. By Henry Morris, m.d., 
Demonstrator of Obstetrics and Diseases of Women 
and Children, Jeff. Medical College. Illus. In Press. 

VIII. DISEASES OF THE EYE AND RE- 
FRACTION. By L. Webster Fox, m.d., Chief 
Clinical Assistant Ophthalmological Dept., Jefferson 
Medical College, and Geo. M. Gould. 60 Illus. 

IX. SURGERY. Including Fractures, Wounds, 
Dislocations, Sprains, Amputations, etc., Inflammation, 
Suppuration, Ulcers, Syphilis Tumors, Shock, etc., 
Diseases of Bladder, Testicles, Anus and other Surgi- 
cal Diseases, Antisepsis, etc. By Orvii.le Horwitz, 
Demonstrator of Anatomy, Jefferson Medical College, 
etc. Third Edition. 91 Illustrations. 77 Formulae. 

X. ORGANIC CHEMISTRY., Including Medical 
Chemistry, Urine and Water Analysis, etc. By Henry 
Leffmann, m.d. 

XL PHARMACY. By F. E. Stewart, m.d., ph.g., 

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Based, by permission, upon " Remington's Text- Book 

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